ACIP Recommends ‘Universal’ Adult HBV Vaccine— But Not for All BY MARIE ROSENTHAL, MS
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risk-based strategy for adult hepatitis B (HepB) vaccination just hasn’t worked, according to Kevin A. Ault, MD, FACOG, FIDSA, the division director of the Department of Obstetrics and Gynecology, University of Kansas Medical Center, in Kansas City. “The risk-based strategy has been given over a decade to prove itself, and that hasn’t panned out because of the complex list of risk factors,” Dr. Ault told the CDC’s Advisory Committee on Immunization Practices (ACIP). The list for at-risk adults is indeed complex. There are four risks under those who might be exposed through sexual contact, such as having multiple partners or living with someone who is hepatitis B surface antigen–positive, and six under the category of those at risk from percutaneous or mucosal exposure to blood, such as injection drug users, those with diabetes and hemodialysis patients. In addition, there are “others”: those at risk because of HIV, chronic liver disease, hepatitis C virus (HCV), incarceration or international travel. And finally, there is a catchall—“all other persons seeking protection from HBV infection.” Determining whether the patient in front of you should be vaccinated is challenging in the time constraints of an office or clinic visit, Dr. Ault said. It’s especially difficult because many patients do not report a risk, added Mark K. Weng, MD, MSc, FAAP, the lead of the ACIP’s Hepatitis Vaccine Work Group. “It’s important to recall that only one-third of people with reported acute hepatitis B actually recorded any risk factors,” said Dr. Weng, who is a medical epidemiologist in the Hepatitis Branch of the CDC. “The current risk-based vaccination strategy provides no advantages in identifying and vaccinating [those] people.”
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It has not been a total wash, he added, because the has been partially successful with initial decreases, but new hepatitis B virus (HBV) infections began to plateau 10 years ago, according to Dr. Weng. The problem is not insignificant. An estimated 1.89 million people live with chronic HBV, and up to 25% of them are at risk for premature death from cirrhosis or liver cancer. About 20,700 acute infections occur annually. Each year, the United States spends more than $1 billion on HBV-related hospitalizations, and this figure does not include indirect costs, according to Dr. Weng, who is a medical epidemiologist at the CDC. “The HepB immunization strategy has evolved over the past four decades,” he said. “Risk-based strategies were first introduced among the adults and perinatally exposed infants in the early 1980s. Then universal infant vaccination was introduced in 1991 with catch-up vaccination recommendations for adolescents in 1999, followed by the introduction of a universal birth dose among all newborns in 2005. All of these steps toward routine HepB vaccination resulted in large declines,” Dr. Weng explained. “However, hepatitis B incidents have plateaued over the past 10 years, with more than 20,000 new infections estimated to occur each year.” HepB vaccination has had the most success among children, because the recommendation is part of the universal childhood immunization schedule, he said. Rates are now highest among adults and have increased among adults 40 years of age and older. The Department of Health and Human Services called for the elimination of viral hepatitis in the United States by 2030,
