**HEPATITIS B AND HAEMOPHILUS IMMUNIZATION PROGRAMS (ALASKA)**

+--------------------+----------+---------------+-----------+----------+
|                    | 2002     | 2003          | 2004      | Increase |
|                    |          |               |           |          |
|                    | Actual   | President's   | Estimate  | or       |
|                    |          |               |           | Decrease |
|                    |          | Budget        |           |          |
+--------------------+----------+---------------+-----------+----------+
| BA                 | \$1      | \$1,556,000   | \$        | \$24,000 |
|                    | ,526,000 |               | 1,580,000 |          |
+--------------------+----------+---------------+-----------+----------+
|                    |          |               |           |          |
+--------------------+----------+---------------+-----------+----------+
| Services Provided: |          |               |           |          |
+--------------------+----------+---------------+-----------+----------+
| \# Hepatitis       | 2,900    | 2,900         | 3300      | +400     |
| Program patients   |          |               |           | (+14%)   |
| given clinical     |          |               |           |          |
| care               |          |               |           |          |
+--------------------+----------+---------------+-----------+----------+
| \# Chronic         | 1,492    | 1,492         | 1350      | -158     |
| carriers surveyed  |          |               |           | (-11%)   |
+--------------------+----------+---------------+-----------+----------+
| Patients           |          |               |           |          |
| Immunized:         |          |               |           |          |
+--------------------+----------+---------------+-----------+----------+
| \# Hepatitis A/B   | 8,400    | 8,400         | 0         |          |
+--------------------+----------+---------------+-----------+----------+
| Hepatitis C        | 900      | 900           | 1100      | +200     |
| patients followed  |          |               |           | (+22%)   |
+--------------------+----------+---------------+-----------+----------+
| Evaluate need for  |          |               |           |          |
| Hep B booster      |          |               |           |          |
| doses:             |          |               |           |          |
+--------------------+----------+---------------+-----------+----------+
| Infants/Children   | 1,982    | 1,982         | 0         |          |
|                    |          |               | \*\*\*\*  |          |
+--------------------+----------+---------------+-----------+----------+
| Adults             | 3,000    | 3,000         | 3,000     |          |
+--------------------+----------+---------------+-----------+----------+
| Immunization       |          |               |           |          |
| Records Audited:   |          |               |           |          |
+--------------------+----------+---------------+-----------+----------+
| \# Trained in RPMS | 90       | 90            | 100       | +10      |
+--------------------+----------+---------------+-----------+----------+
| \# Health Aide     | 80       | 80            | 90        | +10      |
| Training           |          |               |           |          |
+--------------------+----------+---------------+-----------+----------+
| \# Tribal Site     | 0        | 4             | 4         |          |
| Visits             |          |               |           |          |
+--------------------+----------+---------------+-----------+----------+
| Purchases of       |          |               |           |          |
| Vaccine (Adult):   |          |               |           |          |
+--------------------+----------+---------------+-----------+----------+
| Hepatitis A        | \$50,000 | \$50,000      | \$50,000  |          |
+--------------------+----------+---------------+-----------+----------+
| Hepatitis B        | \$50,000 | \$50,000      | \$50,000  |          |
+--------------------+----------+---------------+-----------+----------+

**\***These patients have exams and procedures by hepatitis program
staff field clinics and ANMC.

**\*\***These figures represent patients immunized in hepatitis A/B
studies, and adult vaccination with program-purchased vaccine.

**\*\*\***These figures represent the purchase of adult Hepatitis A and
B vaccines agreed upon in the Alaska compacting tribes funding agreement
with IHS.

\*\*\*\* Provided by the State of Alaska

**[PURPOSE AND METHOD OF OPERATION]{.underline}**

In FY 2004, the Indian Health Service (IHS) Hepatitis and Haemophilus
Influenza Immunization Program (Alaska) will:

-   Reduce the disparity of vaccine-preventable diseases in Alaska
    Natives by coordinating efforts of tribal corporations to improve
    immunization rates

-   Conduct research to improve the effectiveness of vaccination efforts

-   Provide consultation to update and improve the IHS computerized
    vaccine record

-   Provide clinical care and consultation of patients with hepatitis
    and liver disease.

-   Provide support, consultative and educational service for health
    care providers of American Indians/Alaska Natives (AI/AN) in the
    contiguous US.

In FY 2002, with a discretionary base funding of \$1.52 million, the IHS
Hepatitis B and Immunization (Haemophilus) (Alaska) program provides
consultation, training, advocacy, RPMS computer training and technical
assistance, research, clinical care and clinical consultation on
hepatitis to 12 Area Offices (regional) and locally to the 17 Alaska
tribal corporations.

The Viral Hepatitis Program (Hepatitis B Program) and the Immunization
(Haemophilus Immunization) Program are distinct programs of the Alaska
Native Tribal Health Consortium (ANTHC). The Viral Hepatitis Program
provides IHS-and nation-wide and Alaska Native consultation and
expertise on the treatment and prevention of hepatitis A, B, and C and
treatment of liver disease. The program funds support training of
providers and hepatitis specialty clinics throughout Alaska. The program
also provides consultative services for providers nation-wide who care
for AI/AN), including web site materials and guidelines for provider,
patient and public education, telephone and program consultation and
future potential laboratory support. The program operates through grants
to conduct research to improve the prevention and treatment of hepatitis
A, B and C.

The Immunization (Haemophilus) program provides nation-wide IHS and
Alaska-wide tribal consultation on the RPMS immunization software,
immunization strategies, vaccine policies and practice, and immunization
measurement. The Program provides training and technical assistance of
nurses, community health aides (CHAs), and providers in tribal
corporations; advocacy with the State of Alaska to reduce disparities in
Alaska Native vaccine-preventable disease; immunization audits and
technical assistance of local tribal immunization programs; and
grant-writing to assist tribal corporations in improving immunization
delivery. The program collaborates with Arctic Investigations Program --
Centers for Disease Control (AIP) to conduct state-wide disease
surveillance for Haemophilus influenzae (Hib) and Pneumococcus and
conduct research to identify and reduce infectious disease disparities
in Alaska Natives.

+----------------------------------------------+-----------------------+
| [Tribal Contracts:]{.underline}              |                       |
+----------------------------------------------+-----------------------+
| Bristol Bay Health Corps                     | \$ 133,000            |
|                                              |                       |
| Yukan Kuskokwin Health Corp.                 | [228,500]{.underline} |
|                                              |                       |
| Total:                                       | \$ 361,500            |
+----------------------------------------------+-----------------------+

[Tribal Shares]{.underline}: The FY 2003 budget is 100 percent
tribal-administered in the Alaska Tribal Health Compact, and an
agreement by Annual Funding Agreement to support the activities and
personnel described below:

+------------------------------------------------+---------------------+
| Hib Immunization                               | \$ 367,650          |
|                                                |                     |
| Hepatitis                                      | [8                  |
|                                                | 57,850]{.underline} |
| Total:                                         |                     |
|                                                | \$1,225,500         |
+------------------------------------------------+---------------------+
| TOTAL Tribal Contracts and Shares              | \$1,587,000         |
+------------------------------------------------+---------------------+

In addition to direct funds, the Hepatitis & Haemophilus influenza (Hib)
Immunization Program (Alaska) uses grants and cooperative agreements to
expand activities as follows:

+---------------------------+--------------------+--------------------+
| ######                    |                    |                    |
| # Viral Hepatitis Program |                    |                    |
+---------------------------+--------------------+--------------------+
| **Project**               | **Annual Funding** | **Funding Source** |
+---------------------------+--------------------+--------------------+
| Hepatitis A vaccine       | Program Funds      | IHS Appropriation  |
| long-term                 |                    |                    |
|                           |                    |                    |
| efficacy/immunogenicity   |                    |                    |
+---------------------------+--------------------+--------------------+
| Hepatitis B vaccine       | Program Funds      | IHS Appropriation  |
| long-term                 |                    |                    |
|                           |                    |                    |
| efficacy/immunogenicity   |                    |                    |
+---------------------------+--------------------+--------------------+
| Hepatitis B carrier       | Program Funds      | IHS Appropriation  |
| follow-up                 |                    |                    |
+---------------------------+--------------------+--------------------+
| Hepatitis B carrier       | \$40,000           | NARCH + NIH        |
| testing                   |                    |                    |
+---------------------------+--------------------+--------------------+
| Hepatitis C follow-up     | Program + \$44,000 | IHS + NIH and CDC  |
+---------------------------+--------------------+--------------------+
| Hepatitis C molecular     | \$40,000           | NIH NARCH R 01     |
| lab.                      |                    |                    |
+---------------------------+--------------------+--------------------+
| Viral Hepatitis clinical  | Program Funds      | IHS Appropriation  |
| care                      |                    |                    |
+---------------------------+--------------------+--------------------+
| Vaccine purchase          | Program Funds      | IHS Appropriation  |
+---------------------------+--------------------+--------------------+
| Hepatitis A/B             | Program Funds      | IHS Appropriation  |
| immunization              |                    |                    |
+---------------------------+--------------------+--------------------+

+----------------------------+----------------+-----------------------+
| ######                     |                |                       |
| # Hib Immunization Program |                |                       |
+----------------------------+----------------+-----------------------+
| **Project**                | **Annual       | **Funding Source**    |
|                            | Funding**      |                       |
+----------------------------+----------------+-----------------------+
| Immunization               | Program Funds  | IHS Appropriation     |
| audits/training            |                |                       |
+----------------------------+----------------+-----------------------+
| Immunization curricula     | Program Funds  | IHS Appropriation     |
+----------------------------+----------------+-----------------------+
| Tribal corp. site visits   | \$10,000       | Tribal corporations   |
+----------------------------+----------------+-----------------------+
| IHS-wide RPMS training     | \$8,000        | Individual IHS Areas  |
+----------------------------+----------------+-----------------------+
| NARCH Pneumococcal Grant   | \$21,000       | NIH                   |
+----------------------------+----------------+-----------------------+
| Pneumococcal adult Vaccine | \$35,000       | CDC-Office            |
|                            |                | Women/Minority        |
+----------------------------+----------------+-----------------------+

**[ACCOMPLISHMENTS]{.underline}**

##### **Viral Hepatitis Program**

Since its beginnings, in 1982, the Viral Hepatitis Program has reached
all the high-risk villages in Alaska and has the potential for
eradicating hepatitis B. By 1988, the majority of Alaska Natives were
immunized against hepatitis B, if not previously infected. More than 96
percent of Alaska Native newborns receive a dose of hepatitis B vaccine
before hospital discharge.

The annual incidence of acute symptomatic hepatitis B infection has
decreased from 215 per 100,000 prior to 1982, to \< 2 per 100,000, more
than a 100 fold decrease. The 1-year case-fatality rate for primary
liver cancer has decreased from 100 percent to 50 percent, and
significant 10-year survival of liver cancer from early detection has
been documented. Liver function tests were added to the semiannual
screening test for liver cancer (AFP) to identify patients with severe
asymptomatic hepatitis who could be candidates for newly licensed
antiviral medications to prevent end stage liver disease and need for
subsequent liver transplantation. In FY 2002, 217 persons with elevated
liver enzymes with hepatitis B were identified and 17 have been found to
have very active disease and are being treated or evaluated for
antiviral therapy.

Since 1989, the Program has conducted studies on the immunogenicity,
safety and efficacy of hepatitis A vaccine in infants and adults. In
1993 the program, in collaboration with the State of Alaska and four
regional Native health corporations, conducted a project that
demonstrated that one dose of hepatitis A vaccine could halt a large
outbreak of hepatitis A. The Program a study of the effectiveness of
hepatitis A vaccine in infants that demonstrates that this vaccine can
effectively be given to children in endemic areas such as Indian Country
at 1 year of age. Other recent accomplishments include initiation of
studies on hepatitis B boosting and long-term immunogenicity of
hepatitis A vaccines, and the development of a cancer detection program
for persons chronically infected with hepatitis C. The latter has
involved development of a registry of persons with hepatitis C,
currently approaching 1300 Alaska Natives, and, in FY 2002 completed a
program that screened Alaska Natives at high risk for hepatitis C
(persons who received blood transfusions or had cardiac surgery prior to
1992), demonstrating the potential feasibility of such a public health
program for other managed care programs. The program has contacted the
Hepatitis C infected persons twice yearly for AFP testing to detect
liver cancer early and liver function tests to identify potential
treatment candidates.

# **Hib Immunization Program**

Before Hib vaccine, Alaska Natives had one of the highest Hib disease
rates in the world -- over 6 times the U.S. rate. The Program and
AIP-CDC conducted surveillance and research that demonstrated
reemergence of disease with a change in vaccine and advocated with the
State of Alaska for a schedule the Hib vaccine, PedvaxHIB®. Since
instituting this schedule in 2001, there has been only 1 case of Hib
disease in the Alaska children! The program advocated for a combination
vaccine which eased the introduction of new infant pneumococcal vaccine
into the Alaska child vaccine schedule. In just 22 months, this vaccine
has resulted in a 90% decrease in vaccine-type pneumococcal disease in
\< 2 year olds.

In Fall 2002, the Program embarked on a collaborative national project
to revise the IHS Immunization software package for the computerized
Registration and Patient Management System (RPMS). New revisions will
include standardized vaccine, CPT, and manufacturer codes; ability to
forecast combination vaccines; and a new adult immunization audit
report. Expanded tracking and recall using the RPMS immunization package
has revolutionized immunization practice in Alaska tribal corporations.
Since 2001, the number of corporations reporting immunization rates has
increased from 6 to 9 and the age-appropriate immunization rate has
increased from 74% to 77%. Although rural corporations struggle to
maintain on-time immunization rates in remote villagers, the 2-year-old
immunization rate (4DTP, 3polio, 3Hib, 1MMR) among Alaska Natives (87%)
far surpasses the Alaska rate, 74%, and the national average of 77%.
Five corporations already surpass the 90% national 2-year-old goal.

The Program is collaborating with AIP-CDC and tribal corporations in
several important studies. We completed and are publishing results of a
5-year follow-up of early RSV hospitalization that demonstrates
increased risk of wheezing and lower respiratory infections until 4
years of age. In another study, we showed that the expensive RSV
prophylaxis, palivizumab, has resulted in a 3-fold decrease in RSV
hospitalizations in high-risk premature southwest Alaska Native infants.
Using a Native American Research Centers for Health (NARCH) grant, we
are evaluating the spectrum of Alaska Native adult pneumococcal disease
and effect of adult pneumococcal vaccination on invasive disease.

**[RATIONALE FOR BUDGET REQUEST]{.underline}**

**[TOTAL REQUEST]{.underline}** \-- The request of \$1,580,000 is a net
increase of \$24,000 over the FY 2003 President's Budget request of
\$1,556,000.

This increase covers expected personnel increases. The increase does not
address inflation or the expected population increase of 2.1 percent. We
will allocate the budget increase to attempt to meet increasing program
demands including the following anticipated increases:

-   14 percent increase in hepatitis/liver disease patients who receive
    direct clinical services and consultation because of the popularity
    of hepatitis specialty clinics,

-   36 percent in immunization audits and reporting to cover the
    expanded Alaska Native population receiving tribal services and
    reporting immunization rates to IHS,

-   2 percent increase in vaccines purchased to cover population
    increase.

Alaska Native tribal corporations face extreme challenges in
coordinating delivery of vaccines to diverse groups of urban and rural
Alaska Natives. The new pneumococcal vaccine has already resulted in a
90% drop in vaccine-type pneumococcal disease in Alaska Native infants,
but taxes the vaccine delivery system. Recently refrigerator
malfunctions have resulted in spoiled vaccine. With large distances
between villages and high staff turnover, tribal programs are struggling
to maintain or increase on-time infant immunization rates, and programs
have not had the capacity to evaluate adult immunization rates. If
funding remains static, the Immunization program will lose capacity to:

-   Train nurses and Alaska Community Health Aides in immunization
    practice and computerized tracking and recall,

-   Purchase supplemental vaccines, including influenza, adult hepatitis
    A and B vaccines for Alaska Natives,

-   Develop new culturally-appropriate immunization materials and
    curricula and materials for persons with chronic hepatitis,

-   Update the IHS immunization software and evaluate adult immunization
    rates.

-   Maintain model management and treatment, and cancer screening
    programs for persons with chronic hepatitis B and C.

######## Pay Cost Increases: +\$24,000

The \$24,000 will fund tribal pay costs. The IHS continues to strive to
increase access for the IHS patient population. Provision of these funds
is necessary to maintain the current I/T/U health system which works to
eliminate disparities in health status between the American Indian and
Alaska Native population and the rest of the U.S.