ATLANTA – Hepatitis B vaccination should be routinely given to previously unvaccinated adults with diabetes who are younger than 60 years of age, according to recommendations by the Centers for Disease Control’s Advisory Committee on Immunization Practices.
The recommendation is based on the finding that U.S. adults with diabetes patients face a roughly twofold increased risk for hepatitis B infection. Vaccination is advised based on the individual patient’s risk of acquiring hepatitis B infection.
Dr. Sandra Fryhofer
An additional recommendation, which must be published by the CDC before it becomes official, is likely to say that people aged 60 years and older with diabetes who live in nursing homes and assisted living facilities are at increased risk for hepatitis B and should be considered for vaccine prioritization.
Results from CDC investigations identified inadequately cleaned blood glucose monitors as a major route of hepatitis B virus transmission among patients with diabetes, Meredith L. Reilly, a CDC epidemiologist, noted at the earlier annual meeting of the Infectious Diseases Society of America.
"Over the past several years, we’ve observed outbreaks of hepatitis B among patients with diabetes in places where they undergo assisted blood glucose monitoring, with more than one person using the monitor," such as assisted-living facilities, physician offices, and at pharmacies, said Dr. Trudy V. Murphy, head of the vaccine unit in the Division of Viral Hepatitis at the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention in Atlanta. A total of 24 of 28 outbreaks at long-term care facilities identified different aspects of blood glucose monitoring as the source of the infection."
The advised age cutoff was based on estimates of disease risk and cost effectiveness. An analysis of data from more than 91,000 individuals participating in the CDC’s Emerging Infection Program (EIP) found that among people without traditional risk factors for hepatitis B (use of injectable drugs, unprotected sex with multiple partners), the adjusted odds ratio for acute hepatitis B among those with diabetes was 1.89, compared to those without diabetes, suggesting that diabetes is an independent marker for the infection, according to the CDC’s Dr. Sarah Schillie.
Among people with hepatitis B risk factors, those with diabetes had a 1.1 odds ratio of infection, compared with non-diabetics in that group.
After controlling for sex, race/ethnicity, and age, the overall odds ratio for acute hepatitis B among those with diabetes compared with those without was 2.09 in people aged 23-59, which was statistically significant. Among adults aged 60 and older, the odds ratio was 1.45, which was not significant.
The costs per quality-adjusted life year (QALY) saved of vaccinating adults with diabetes (assuming the private vaccine price), was calculated to be $75,094 for adults aged 20-59, compared with $2,8 million among those aged 60 and older, Dr. Schillie reported.
Many more patients with diabetes are sharing glucose monitors in a wide variety of settings, including households in which more than one family member has diabetes, worksite health clinics, schools, and diabetes camps. "We’re seeing more and more use of one glucose meter for multiple people," noted Dr. Pam Allweiss of the CDC’s Division of Diabetes Translation.
Because a large proportion of people with diabetes who are in institutions are older than 60, the ACIP debated whether to simply recommend the hepatitis vaccine for everyone with diabetes, rather than using cost-effectiveness as a guide for the age cutoff.
Prior to the vote, American College of Physicians liaison Dr. Sandra Fryhofer said that the ACP’s Adult Immunization Technical Advisory Committee supported a universal recommendation: "I urge you to recommend routine hepatitis B vaccination for diabetics of all ages," she told the ACIP.
In an interview after the vote, Dr. Fryhofer said of the College’s vaccine advisory committee, "We’re disappointed that we didn’t have a routine hepatitis B immunization recommendation for all diabetics of all ages. We know that diabetes is the 7th leading cause of death in this country, and the data show that if you have diabetes, it increases your risk of getting hepatitis B by 1.5 to 2 times, and it doubles your risk of death." However, she said, it’s unlikely that ACP will issue a different recommendation from ACIP’s.
Dr. William E. Golden
Internist William Golden, however, disagreed with the idea of a universal approach. "Vaccinating everyone probably should not be a knee jerk reaction. ... One should first check to see if the patient already has antibodies conferring immunity. Secondly, one should inquire or warn about risks of sharing equipment. Make sure the patient has insurance coverage for the injections to avoid unpleasant surprises. Finally, review the need for frequent home glucose checks," he said. "Stable type 2 diabetics on oral medication may not need home checks more than one or two times a week, if at all. So, in short, assess the risks for the patient before offering a one size fits all strategy," said Dr. Golden, professor of medicine and public health at the University of Arkansas for Medical Sciences, Little Rock.