In a 12-2 vote, members of Advisory Committee on Immunization Practices recommended for hepatitis B virus vaccination in unvaccinated adults with diabetes who are aged younger than 60 years, and that the vaccine may be administered to unvaccinated adults with diabetes who are aged at least 60 years.
During the meeting, Mark H. Sawyer, MD, chairman of the ACIP working group, said this recommendation was prompted by a number of outbreaks of HBV in institutional settings.
Mark H. Sawyer, MD
"We have learned that there is an increased risk for HBV in the general adult population with diabetes, and that this increased risk appears to be associated with assisted blood glucose monitoring (when equipment is shared and adequate hand hygiene procedures are not in use), which occurs in a wide variety of settings," said Sawyer, of the University of California, San Diego. "We've reviewed the literature on infection control practice in diabetes care and monitoring, which are intended to prevent transmission of infection when assisted blood glucose monitoring is achieved. In doing so, our work group has concluded that infection control measures alone are unlikely to be sufficient to prevent subsequent outbreaks."
Trudy Murphy, MD, of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, said: "With the information on the increased risk for HBV among adults with diabetes, the working group considered the potential benefits that might be achieved by vaccination, how age of diabetes diagnosis may affect the proportion of those who would be protected by vaccination, and the cost-effectiveness of vaccination related to age. These considerations led to the formulation of the proposed recommendations."
Murphy presented 2009-2010 data from the Emerging Infection Program that indicate approximately a twofold increased risk for acute HBV infection among adults aged 60 years and younger with diabetes compared with adults without diabetes. A slight increased risk was observed in adults with diabetes aged older than 60 years.
She also presented results from a cost-effective analysis that suggested an HBV vaccination program would be most cost-effective among those with diabetes aged younger than 60 years — with savings of approximately $75,000 for quality-adjusted life year gained.
"Modeling estimates demonstrate that an HBV vaccination program with 10% coverage among adults with diabetes aged between 20 and 59 years would be expected to avert 4,271 HBV infections, 467 hospitalizations, 202 cases of cirrhosis, 33 cases of hepatocellular carcinoma, 13 liver transplants and 130 deaths," said Sarah Schillie, MD, MPH, MBA epidemic intelligence service officer for the CDC. – by Ashley DeNyse
Disclosure: Drs. Murphy and Schillie report no relevant financial disclosures.
This is an interesting finding regarding increased rates of HBV in
patients with diabetes. It seems that the risk would certainly be highest in
patients who require hospitalization or other institutional care, as they will
be exposed to assisted glucose monitoring. Targeting this particular subset of
the diabetes population would likely increase the benefits of a vaccination
program even further. These patients may include those with type 1 diabetes
with frequent episodes of diabetic ketoacidosis, those with multiple
complications, and older patients in skilled nursing facilities. Given the
large percentage of patients with diabetes (around 8% of the population), this
recommendation could greatly expand the level of HBV vaccination nationwide.
– Dawn Belt Davis, MD, PhD
University of Wisconsin-Madison
Disclosure: Dr. Davis reports no relevant financial