Survey: PCPs need greater hepatitis B vaccination awareness

Primary care physicians do not realize how low the rate of adult hepatitis B vaccination is in the United States, according to a small survey.

Results of the survey, which were presented at the National Foundation for Infectious Diseases Annual Conference on Vaccinology Research, showed that 0% of providers knew the adult HBV vaccination coverage rate is just 25%.

Researchers surveyed just under 30 PCPs at a Connecticut Community Health Center to evaluate their awareness of HBV and identify opportunities to increase HBV vaccination.

They found that 86% of respondents incorrectly believed the vaccination rate was significantly higher, at 75%. They also found that 29% of participants did not know that the Advisory Committee on Immunization Practices (ACIP) recommends that any patient who requests an HBV vaccine should receive the vaccination, and that 14% of participants did not know that chronic HBV can lead to liver cancer without cirrhosis.

Among the participants, 86% reported that they cared for 10 to 19 patients with at least one HBV risk factor in the last month and 43% reported seeing 20 or more patients with a risk factor. However, 43% had not considered testing any of their patients for HBV in the last month, 29% had not considered vaccinating their patients in the past month, and 71% ordered HBV vaccinations for less than five patients during that time.

After attending an educational session on HBC, 100% of PCPs said they were more likely to order HBV testing and vaccination for their adult patients.

Although the survey focused on a relatively small number of PCPs, the researchers are developing strategies to raise awareness about HBV vaccination rates across the U.S. — which is particularly important during the opioid epidemic.

The team has already successfully collaborated with members of the United States Congress to introduce a Congressional resolution designating April 30 as National Adult Hepatitis B Vaccination Awareness Day (H.Res. 331/S.Res.177—116^th Congress).

Healio Primary Care spoke with Rita K. Kuwahara, MD, MIH, lead author of the study, to learn more about the findings and the researchers’ advocacy efforts. Kuwahara is an internal medicine resident physician who cares for patients at the Connecticut Institute for Communities Inc., and is the formal federal health policy fellow at the Association of Asian Pacific Community Health Organizations.

Q: What prompted you to conduct this study?

A: When I was initially working on this project, I was the federal health policy fellow working on hepatitis B policy with the Association of Asian Pacific Community Health Organizations, which represents community health centers across the country. In my role as a policy fellow, I was trying to figure out how to decrease the rates of chronic and acute HBV in the United States. What was most striking when I was looking at the data was that, for example, Maine had a 729% increase in acute HBV from 2015 to 2017; Kentucky, West Virginia and Tennessee had a 114% increase from 2009 to 2013; southeastern Massachusetts had a 78% increase in 2017; and North Carolina had a 62% increase from 2012 to 2016. That mirrored what was happening with the opioid epidemic. It looked like the rises in acute HBV correlated with the states most heavily affected by current opioid crisis that was occurring nationwide.

When I started to develop policy strategies to stem the acute rise in HBV in our nation, I saw that HBV is a vaccine-preventable disease, so asked the question: why are we having such acute rises when an HBV vaccine exists? The National Foundation for Infectious Diseases had compiled very striking data that showed only 25% of adults are vaccinated against HBV. When you look at the subcategories, for example, in individuals over the age of 65 years with diabetes, the vaccination rate is only 12%. The reasons for these low rates of vaccination in the adult population is because universal childhood HBV vaccination only was implemented in the mid-1990s in the U.S. This policy was implemented in slightly different time periods across the country. So, a lot of adults younger than the age of 20 years to 25 years would have been vaccinated at birth and in early childhood if they grew up in the U.S., but if they were older than 25 years, then they likely didn’t get vaccinated. Some 20- to 30-year-olds might have gotten a catch-up vaccine series if they went to college and it was required for enrollment. Aside from that, if you are looking at individuals most at risk for the opioid crisis, it is the individuals aged 25 to 45 years. Those are the people who are not vaccinated against HBV.

When you have outbreaks of disease, vaccines are usually the answer. The question is: Why aren’t we vaccinating more? That’s what prompted my study to look at opportunities to increase vaccination and to explore why rates are so low.

Q: You worked with members of Congress to introduce a U.S. Congressional Resolution to designate April 30 as National Adult Hepatitis B Vaccination Awareness Day. What was that process like?

A: This Congressional resolution was introduced on April 30, 2019, during the first session of the 116th Congress. It is U.S. House of Representatives Resolution 331 and U.S. Senate Resolution 177. In the House, it was introduced by Congressman Hank Johnson of Georgia and Congresswoman Grace Meng of New York. It has bipartisan support in the House. In the Senate, it was introduced by Senator Mazie Hirono of Hawaii and Senator Angus King of Maine. The resolution was also endorsed by more than 75 medical associations and professional societies, including the AMA, ACP, AAFP, the American Medical Women’s Association, the American Public Health Association, the American College of Obstetricians and Gynecologists, and a number of others.

Members of Congress are increasingly supporting efforts to address these acute rises in HBV within the opioid crisis and are continuing to support this resolution, although we are continuing to look for additional congressional support for this resolution both within the U.S. House of Representatives and U.S. Senate.

A large portion of this Congressional resolution is about awareness building. The low HBV vaccination rate is not an issue of payment or affordability; it is really an awareness issue. The adult HBV vaccine is available with no cost-sharing for patients who have Medicare, private insurance and most of Medicaid. It is covered the same way influenza vaccines are covered under Medicare Part B. But I think some of the challenges from a primary care standpoint is that for adults, HBV vaccination is risk-based, not universal. A clinician has to consider if a patient has one of a number of risk factors, so ordering the HBV vaccine has not turned into a reflex action for clinicians. People who are considered at risk for HBV include anyone who is HIV positive, individuals who inject drugs, men who have sex with men, individuals who have chronic liver disease, people with hepatitis C, anyone with diabetes, anyone with end-stage renal disease on hemodialysis, pregnant women, anyone on immunosuppressive therapy, anyone from a region of the world with a greater than 2% prevalence of HBV, any incarcerated individuals, all health care personnel and any household contacts or sex partners of people with chronic HBV. This is an extensive list. Still, HBV vaccination has not really been incorporated into primary care the way that influenza, pneumonia and — in older adults — shingles vaccination has been incorporated. I also think that a lot of individuals in the community are not aware of HBV or that the HBV exists for adults, so they wouldn’t necessarily ask their PCPs about it. That’s why we thought that an awareness campaign both on the provider side as well as the patient side would help to increase vaccination levels.

According to the [ACIP], any adults who request HBV vaccination can get vaccinated. They don’t have to have a risk factor. So again, this an awareness issue, which is why we thought the Congressional Resolution and other opportunities to increase awareness would be helpful.

Q: In your opinion, what were the most alarming findings of your survey? What stood out to you the most?

A: The biggest finding that stood out to me was that 0% of PCPs surveyed knew that the adult hepatitis B vaccination rate is only 25% in the U.S., and 86% of physicians surveyed incorrectly thought that the vaccination rate was at least 75%. We surveyed internal medicine resident and faculty physicians who practice adult medicine. There is this misbelief that physicians do not need to address HBV vaccination in adults because the pediatricians took care of it, but this was only implemented 20 to 25 years ago, leaving a majority of today’s adults unvaccinated. We really need to be looking at opportunities to increase HBV vaccination in a large portion of our adult patient population.

Q: What advice do you have for PCPs?

A: It is important to be aware of the low adult HBV vaccination rates so that we are routinely thinking about vaccinating our patients against HBV.

One challenge with the HBV vaccine historically is that it has been a three-dose vaccine for adults that span a 6-month period. There is the newer Heplisav-B vaccine (Dynavax) that can be administered as a two-dose series over the course of 1 month. I think that a lot of PCPs are increasingly aware of this, but it might not be as well known, especially if they are not routinely vaccinating their patients against HBV. Being aware of the various vaccination options is important. And because this is a multi-series vaccine — whether it’s a two-dose or three-dose vaccine — making sure that systems are implemented so that patients come back for their subsequent doses is really key, as well.

From a policy perspective, I think that right now the No. 1 priority is around COVID-19 for obvious reasons. What is concerning is that because we have migrated to telehealth encounters with our patients, and we are not currently physically seeing our patients in the office, they are not getting their vaccinations. Making sure that there is funding and support for programs and primary care-focused initiatives that support vaccination programs is really important in the context of the COVID-19 pandemic because we don’t want to have new outbreaks of vaccine-preventable diseases when we are already grappling with a much larger pandemic.

Q: Is there anything else you wanted to add on this topic?

A: Viral hepatitis has recently had a lot of attention in the clinical world as well as in the news. For example, hepatitis C now has a cure and made headlines due to how expensive the new medications were. If we test and treat everyone for HCV, then we can eliminate HCV. While HBV has no cure, there is a vaccine available to prevent HBV infection. We need significantly expanded testing for HBV to diagnose all those with chronic HBV, but if we are able to vaccinate everyone who is susceptible to HBV, then we can at least prevent any new HBV infections. In effect, between increasing HBV vaccination for adults, maintaining universal childhood vaccination, and providing curative treatment for HCV, we can actually end the chronic viral hepatitis epidemic. So, it is really important for us to increase this awareness, so that we can end new HBV infections through increased vaccination.

Hepatitis A has also been in a lot of headlines recently because there have been acute rises in HAV incidence. HAV only causes acute infection, so people will become acutely ill, but they won’t develop ongoing chronic viral hepatitis. I think there are currently some missed opportunities in public health and primary care. A lot of programs were being implemented to increase HAV vaccination, but the same people who are at risk for HAV would be at risk for HBV. It’s important that any HAV vaccine initiatives are also simultaneously working to increase adult HBV testing and vaccination.

The reason why it is so important to prevent HBV infection is because 25% of individuals with unmanaged chronic HBV will develop liver cancer, liver failure and/or cirrhosis. Those can have very deadly outcomes. The survival rate for liver cancer over a 5-year period is less than 20%. If we are able to prevent HBV infection through vaccination, that can make a huge difference in outcomes. The HBV vaccine was the first anti-cancer vaccine to be developed. I think framing it as an anti-cancer vaccine is very valuable. We have a vaccine that prevents cervical cancer, and guidelines now support that vaccine in men and women and have expanded the age groups. I think using that same framing of the HBV vaccine as an anti-cancer vaccine is important, especially when you see acute rises in HBV amid the opioid crisis, which hasn’t necessarily been stopped or slowed during the COVID-19 pandemic. When COVID-19 is more under control, there is still the underlying issue of the opioid crisis.

Being able to address infectious disease consequences of the opioid epidemic is key. The U.S. Congress has recognized the importance of this and even included in the larger opioid bill that was enacted into law during the last Congress a subsection on the importance of addressing the infectious disease consequences of the opioid epidemic. This section of the bill states that we need to support the CDC and public health programs to address HBV and HCV within the opioid epidemic. Congress has since authorized funding specifically for that section of the opioid bill.