ACIP delays vote on hepatitis B virus vaccine for diabetes

Issue: December 2010

Issues that include cost-effectiveness and frailty among older adults with diabetes remain unresolved as the Advisory Committee on Immunization Practices continues to discuss hepatitis B virus vaccination.

Kathy Byrd, MD, of the Division of Viral Hepatitis and the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention at CDC, discussed hepatitis B virus (HBV) vaccine coverage in high-risk adults, including high-risk heterosexuals, injection drug users and men who have sex with men.

“Some data show that HBV vaccination rates are 51% in high-risk adults and 41% in low-risk adults,” Byrd said. “We need to improve this coverage.”

She said the highest risk age is 18 to 20 years, regardless of risk behavior status, and individuals with more frequent access to health care systems have better vaccination uptake.

“However, coverage for high-risk groups, including health care workers, remains low,” Byrd said.

Mark Sawyer, MD, chair of the Advisory Committee on Immunization Practices Hepatitis Working Group, provided an overview of items for discussion within the 25-person group.

“The vote on HBV vaccination has been delayed because it is a complicated topic,” he said. “There are many areas of concern, including cost-effectiveness.”

Sawyer said other points of discussion include further defining risk factors for HBV and morbidity and mortality as stratified by age and health care setting.

“We are particularly interested in addressing infection control practices in diabetes care and management, and defining the characteristics of long-term care that are applicable,” he said.

Regarding vaccination, Sawyer said the group is discussing factors contributing to seroprotection and issues surrounding revaccination and duration of protection.

Infection control

Joseph Perz, MD, of the National Center for Emerging and Zoonotic Infectious Diseases at CDC, discussed infection control initiatives involving HBV.

“In the last 22 months, we have seen seven outbreaks of HBV in settings where patients are receiving assisted monitoring of blood glucose,” Perz said, adding that two of those outbreaks occurred across multiple assisted living facilities.

“Since 1990, there have been 26 outbreaks associated with assisted monitoring of blood glucose,” he said. “Despite efforts at control, outbreaks continue to mount. The shared use of blood-contaminated equipment increases transmission of blood borne pathogens.”

Perz said many assisted living facilities are not subject to national or uniform guidelines, and that the standard of care can suffer as a result. “Misuse of equipment has been seen in such facilities as acute care centers and ambulatory care centers,” he said. “Continued efforts are needed to stress adherence to control practices.”

Patients with diabetes

Trudy Murphy, MD, of the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention at CDC, reviewed data on HBV in adults with diabetes and discussed policy considerations for HBV vaccination in adults with diabetes.

“We are seeing that about 18% of adults with diabetes had evidence of past or current HBV infection,” Murphy said. “Compare this with 5.2% among individuals without diabetes.”

She said after many months of review, the working group is considering a recommendation to vaccinate all adults with diabetes as soon as possible after diabetes diagnosis. Murphy noted, however, that some gray areas remain with regard to cost-effectiveness, seroprotection rates and duration of protection among older adults.

“It may be recommended to leave vaccination of frailer adults up to clinician judgment,” she said. “However, among most populations with diabetes, vaccination could decrease the burden of acute HBV, offer protection before the onset of complications, reduce reservoirs of HBV that contribute to chronic infection and decrease chronic liver disease, carcinoma and liver mortality.”

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