Expanding hepatitis B vaccine recommendations for adults

My colleagues at the Advisory Committee on Immunization Practices (ACIP) are examining a proposed policy for hepatitis B vaccination for diabetic patients. If accepted, this would be the next in a series of baby steps expanding hepatitis B vaccine recommendations for adults. While we are taking these baby steps, HBV incidence rates among U.S. adults remain pretty flat, and they haven’t changed much since 2006.

We know the vaccine works. We can tell because one of our previous baby steps (the one actually involving babies) was universal vaccination of infants and screening of pregnant women put in place in 1991. That was followed by the recommendation for the universal immunization of all children and adolescents. Since then, hepatitis B rates in these age groups have plummeted. That’s not surprising. Comprehensive vaccination leads to these kinds of results while targeted vaccination can lead to, well, not much.

In the case of HBV, we are dropping the ball for adults. Just as young adults enter the period of life when the risk of exposure increases, they enter the period when the vaccine is no longer recommended universally. Indeed, you first have to incur some risk before you are eligible for vaccination. Hmmm … I thought the concept of prevention was to provide vaccine before the individual was exposed.

This paradox becomes even more evident when you consider that, according to ACIP, since 1991 we have had a strategy aimed at the elimination of HBV transmission here in the United States. Some strategy: we wait for the immunized children and adolescents to grow up. That’s not a strategy, that’s lethargy.

Targeted HBV immunization program for adults has stalled. This may have more long-term health implications than we realize. We already know that 30% of all liver cancers in the United States are caused by HBV. Now there is a new study from investigators at the NIH and in South Korea showing that individuals with HBV are twice as likely to develop non-Hodgkin’s lymphoma.

We already know more than enough about the benefits and safety of HBV vaccination to advocate for a broad recommendation for the immunization of adults. Indeed, HBV vaccine already is recommended for “sexually active persons who are not in a long-term, mutually monogamous relationship”. Not very well known, this already verges on a universal recommendation for unmarried young adults (and many older adults).

Enough with the baby steps — let’s take a substantial adult leap and extend the recommendation for universal HBV vaccination beyond the 19th birthday into adulthood. That would be a real strategy to eliminate transmission of this virus in the United States.

William Schaffner is Professor and Chair, Department of Preventive Medicine, Vanderbilt University School of Medicine, and blogs at Infectious Disease News.

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