The Advisory Committee on Immunization Practice’s
recent vote in favor of hepatitis B vaccination for all
patients with diabetes aged younger than 60 years is a giant step
forward for millions of Americans.
The vote reflects the new information that adults with
diabetes aged younger than 60 years are twice as likely as age-matched adults
without diabetes to get hepatitis B and also that adults with diabetes might
experience greater morbidity and mortality from the infection.
My “glass half-full” nature is very happy that
millions more Americans will benefit from a safe and effective vaccine. But, my
“glass half-empty” side still wonders
why we keep taking baby steps. This is a move in the
right direction, but universal adult hepatitis B vaccination would have been
even better. Each person with diabetes we protect from hepatitis B infection is
one less person in the disease reservoir, and that’s good, but a more
comprehensive strategy to interrupt the transmission of hepatitis B virus would
be even better.
Our current strategy is timid. We stress universal
hepatitis B vaccination through age 18 years, but by stopping at the 19th
birthday — just at a time when young adults gain more independence and are
more likely to engage in behaviors (specifically, sexual behaviors) that
increase the risk for acquiring hepatitis B virus — we make it more
difficult for them to get the protection they need.
Enough about what we don’t have; let’s take a
closer look at the new ACIP recommendation. As always, the hard-working members
of the ACIP reviewed all manner of related data in painstaking detail.
This includes vaccine efficacy and safety, disease
incidence and burden, integration of the vaccine into the immunization
schedule, the potential effect on other vaccines given at the same time,
cost–benefit, and so on. Sometimes, not all data point in the same
direction, and you end up with a policy with some paradoxes.
Watch this: The recommended vaccination age for adults
with diabetes stops at age 60 years. This correlates nicely with the fact that
cost–benefit and vaccine efficacy both decline with age. Here’s the
paradox — it was hepatitis B outbreaks in adults with diabetes aged older
than 60 years in nursing homes, assisted living facilities and hospitals that
spurred the ACIP to take a look at this issue in the first place. Now, those
same people will not benefit from the new recommendation.
The “age 60 stop” also creates a unique
coverage gap. Private and public insurers are likely to pay for hepatitis B
vaccine for adults with diabetes in the recommended 19- to 59-years-old age
range, and Medicare Part B already pays for hepatitis B vaccine in full if a
doctor says it’s necessary for patients aged at least 65 years.
That leaves those with diabetes aged 60 to 64 years out
in the cold. Yet another paradox — vaccination as soon as possible after
diabetes diagnosis will maximize protection, but
15.6% of all diabetes diagnoses are made in this age
group, and lack of coverage may force them to wait until age 65 years
to get vaccinated.
I’d like to see a more comprehensive hepatitis B
immunization program, but as Roy Rogers might say: “Let’s not look a
gift horse in the mouth.”
As infectious disease professionals, we need to start
raising awareness of this new recommendation now, so our colleagues who provide
regular care to patients with diabetes can be ready to vaccinate in the coming