High-Risk Groups Not Receiving Vaccinations Against Hep A, B

ISSUE: JUNE 2011 VOLUME: 62:06
by Christina Frangou

Chicago—Most adults who have chronic liver disease or type 2 diabetes do not receive the recommended vaccinations against hepatitis A and B viruses (HAV and HBV), even though these groups are considered at high risk for severe liver injury if they are acutely infected, said researchers at the 2011 Digestive Disease Week (DDW) meeting.

“Despite the fact that these people are at very high risk for severe liver injury, they are not vaccinated at the level you would expect,” said Zobair Younossi, MD, vice president of research for Inova Health System in Falls Church, Va., and executive director of the Center for Liver Diseases at Inova Fairfax Hospital. “We must consider other ways to distribute the vaccine, perhaps having it available in gastroenterology offices and primary care physicians’ offices,” he said.

Acute hepatitis A or B in patients with chronic hepatitis C can cause severe hepatic injury and a higher fatality rate than in patients without hepatitis C. Additionally, patients with type 2 diabetes—many of whom have undiagnosed nonalcoholic fatty liver disease (NAFLD)—also can have severe liver problems. HAV and HBV infections are vaccine-preventable diseases, and studies have confirmed the vaccines are safe and effective in patients with chronic liver disease or diabetes. As a result, several medical societies, including the American Association for the Study of Liver Diseases, the American College of Gastroenterology, the Infectious Diseases Society of America and the National Institutes of Health, recommend that all patients with chronic HCV who are not immune to HAV and HBV be vaccinated.

In the current study, investigators examined data from two cycles of the National Health and Nutrition Examination Survey (NHANES; 1999-2004 and 2005-2008), which included 22,466 adults. Of these, 3,239 individuals had chronic liver disease (hepatitis C, 12%; NAFLD, 68.7%; other liver diseases, 19.3%) and 2,480 individuals had type 2 diabetes. In the 2005-2008 period, 20% and 32% of patients with chronic liver disease reported receiving HAV and HBV vaccinations, respectively. For the same years, vaccination rates among diabetic persons were lower—15.6% for HAV and 21.8% for HBV.

Vaccination rates are rising. However, the high-risk groups are improving at the same pace as the general population. Overall, HAV vaccinations increased by approximately 6.9% from 1999-2004 to 2005-2008 in persons with chronic liver disease, and HBV vaccinations rose by 8.6%, both paralleling the increase in the control population. In individuals with diabetes, vaccination rates rose by 6.2% and 6.1% for HAV and HBV, respectively.

The low vaccination rates likely result from several factors. Health care providers may not appreciate the importance of HAV and HBV vaccinations in these high-risk patients. Additionally, there may be barriers to access; for instance, the vaccines are administered according to a fixed schedule over several months, and doctors’ offices may not be equipped to administer and store vaccines.

“This is an important public health issue, and public health policy makers need to develop strategies to make better vaccination mechanisms available to individuals with chronic liver disease,” Dr. Younossi remarked.

Health care providers should look at how drugstores, pharmacies, community health centers and other places could raise vaccination rates. Pharmacies could improve vaccination rates by providing the vaccine, Dr. Younossi suggested. “So a physician could write an order to have a vaccination done in a pharmacy, which could be easier to implement.”

On May 12, four days after Dr. Younossi presented his study, the U.S. Department of Health and Human Services released an action plan for prevention, care and treatment of patients with hepatitis. The plan calls for improvement in provider education, public awareness and access to health care services. Among the goals, “universal hepatitis A and hepatitis B vaccination for all vulnerable adults” is recommended.

By 2012, the department wants new strategies to expand access to the vaccines in the primary care setting. And by 2013, it wants to see expansion of vaccine delivery to pharmacies.

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