William Schaffner, MD, is professor of preventive medicine and medicine (infectious diseases) at Vanderbilt University School of Medicine in Nashville, Tenn. Additionally, he serves as a hospital epidemiologist at Vanderbilt University Hospital and is immediate past-president of the National Foundation for Infectious Diseases.

One giant leap for diabetes, one small step for society

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 months.