Since 1996, 29 outbreaks of hepatitis B virus (HBV) infection in long-term care facilities have been reported to the CDC, 25 of which involved adults with diabetes who were receiving assisted blood glucose monitoring. As a result of these reports, the Hepatitis Vaccines Work Group of the Advisory Committee on Immunization Practices (ACIP) created recommendations for hepatitis B vaccination for adults with diabetes that were published in Morbidity and Mortality Weekly Report.
Significant Findings & Recommendations
According to our investigation, people aged 23 to 59 who had diabetes had 2.1 times the risk of developing acute HBV when compared with those without diabetes. For those aged 60 or older, patients with diabetes were 1.5 times more likely to acquire HBV than those without the disease. The annual incidence of reported acute HBV infection among adults with diabetes is 1.8 per 100,000. It’s believed that an additional 10.5 new cases of HBV infection occur for each reported confirmed case. Data from 2009-2010 Emerging Infections Program sites indicated that the case-fatality rate among HBV-infected people with diagnosed diabetes was 5%, compared with 2% for people without diabetes. On the basis of available information (including information about HBV risk, morbidity and mortality, and cost-effectiveness), the ACIP recommended the following:
1) Unvaccinated adults with diabetes aged 19 to 59 should receive the hepatitis B vaccine.
2) At the discretion of clinicians, the hepatitis B vaccine may be administered to unvaccinated adults with diabetes aged 60 and older.
The ACIP recommendation for adults aged 60 and older is not as strong as the recommendation for adults aged 19 to 59 because the estimated cost per quality-adjusted life-year saved appeared to increase substantially with advancing age, and the hepatitis B vaccine becomes less effective as patients age. The hepatitis B vaccine series was associated with the rates of protective response shown in the Table.
While the duration of immunity among patients with diabetes who receive the hepatitis B vaccine is unknown, protection against symptomatic and chronic HBV infection has lasted longer than 22 years among healthy vaccine responders in clinical studies. As a result, vaccinating those with diabetes aged 19 to 59 may allow for protection against the virus before these patients enter longterm care, where the majority of HBV outbreaks associated with assisted blood glucose monitoring have occurred.
Putting Recommendations Into Practice
Clinicians should vaccinate patients as soon as feasible following a diagnosis of diabetes. In patients with diabetes who are 60 or older, consideration of the patient’s risk of acquiring HBV infection, likelihood of experiencing chronic sequelae if infected, and the declining immunologic response to vaccines associated with frailty should help guide the decision to vaccinate.
Readings & Resources (click to view)
CDC. Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2011;60:1709-1711. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a4.htm.
Thompson N, Perz J. Eliminating the blood: ongoing outbreaks of hepatitis B virus infection and the need for innovative glucose monitoring technologies. J Diabetes Sci Technol. 2009;3:283-288.
CDC. Viral hepatitis surveillance—United States, 2009. US Department of Health and Human Services; 2011. Available at www.cdc.gov/hepatitis/statistics/2009surveillance/index.htm.
Hyams K. Risks of chronicity following acute hepatitis B virus infection: a review. Clin Infect Dis. 1995;20:992-1000.
El-Serag H, Tran T, Everhart J. Diabetes increases the risk of chronic liver disease and hepatocellular carcinoma. Gastroenterology. 2004;126:460-468.
Klonoff D, Perz J. Assisted monitoring of blood glucose: special safety needs for a new paradigm in testing glucose. J Diabetes Science Technol. 2010;4:1027-1031.
Leuridan E, Van Damme P. Hepatitis B and the need for a booster dose. Clin Infect Dis. 2011;3:68-75.
Yao X, Hamilton R, Weng N, et al. Frailty is associated with impairment of vaccine-induced antibody response and increase in post-vaccination influenza infection in community-dwelling older adults. Vaccine. 2011;29:5015-5021.