COMMENTARY

Hepatitis B Vaccine for Adults With Diabetes

Trudy Murphy, MD

Disclosures

July 23, 2012

Editorial Collaboration

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Hello. My name is Dr. Trudy Murphy. I am the Chief of the Vaccine Research and Policy Team in the Division of Viral Hepatitis at the Centers for Disease Control and Prevention (CDC). As part of the CDC Expert Video Commentary series on Medscape. I will be speaking with you today about the new recommendation to vaccinate adults with diabetes mellitus against hepatitis B virus infection; this includes adults with both type 1 and type 2 diabetes.

CDC's Advisory Committee on Immunization Practices (ACIP) has previously recommended hepatitis B vaccine for all children and adolescents through 18 years of age. Hepatitis B vaccine also is recommended for adults who are at increased risk for hepatitis B infection, including adults who are healthcare workers. ACIP recently added adults with diabetes to the list of persons at increased risk for hepatitis B infection and recommended that they receive hepatitis B vaccination.

In an investigation[1] conducted by CDC, more than 800 cases of acute hepatitis B that occurred among adults during 2009 and 2010 were evaluated for whether the patients were diagnosed with diabetes or had known risks for hepatitis B infection. The investigation found that adults with diabetes who were younger than 60 years of age had twice the risk for acute hepatitis B infection as adults without diabetes of the same age. Adults with diabetes who were 60 years of age and older also were at increased risk for hepatitis B infection, but the increase was smaller than for younger adults and was not statistically significant.

To protect against hepatitis B, ACIP now recommends hepatitis B vaccination for all unvaccinated adults with diabetes who are younger than 60 years of age. Vaccination should occur as soon as possible after diagnosis of diabetes, and vaccination should also be given to adults diagnosed with diabetes in the past.

Vaccination requires 3 doses at 0, 1, and 6 months, although other schedules are available. Longer intervals between doses are possible so that it is not necessary for patients to make extra medical visits for vaccination. However, longer intervals will leave adults with diabetes at risk for hepatitis B infection until the vaccination series is completed.

For unvaccinated adults with diabetes who are 60 years of age and older, ACIP recommends hepatitis B vaccination at the discretion of their care provider. As with other vaccines, the efficacy of the hepatitis B vaccine decreases with advancing age. The benefits of the vaccine series may be relatively limited for older patients with diabetes who are very frail or who have other reasons to anticipate a reduced life expectancy. However, hepatitis B vaccination may provide partial, if not full, protection for other older adults with diabetes. The duration of protection is more than 20 years for young adults but has not been determined for older adults with diabetes.

Factors that might support vaccinating adults with diabetes aged 60 years and older include temporary or permanent residence in a long-term care facility such as a nursing home or assisted-living facility, reliance on assisted blood glucose monitoring as might occur for persons receiving home healthcare, and recent diagnosis of diabetes in older adults with generally good health.

The hepatitis B vaccine series can be safely given to adults at any age. Hepatitis B vaccine has been given to millions of children and adults of all ages worldwide. The safety of the vaccine was recently reviewed and reconfirmed by the Institute of Medicine in 2011.[2]

As you know, hepatitis B is a viral infection of the liver that can cause serious illness in adults. About 40% of adults with hepatitis B require hospitalization, and at least 4% of adults die from early complications of the infection. About 5% of adults with hepatitis B go on to develop chronic hepatitis B infection; the risk for chronic hepatitis B is considerably higher for adults with renal failure. Among adults with chronic hepatitis B, 15% have progression to cirrhosis and liver failure or liver cancer.

Hepatitis B virus is easily transmitted. Infectious quantities of virus can be found in amounts of blood or other body fluids too small to be visible. The virus is stable and remains infectious for 7 days or more on environmental surfaces where, if touched, it can be introduced at sites where skin is disrupted. The small infectious dose and the stability of the virus both facilitate transmission. More than 25 outbreaks of hepatitis B among adults with diabetes have occurred in long-term care facilities. Transmission in these settings has been linked to inadequate cleaning of blood glucose meters, especially when adults were receiving assistance with blood glucose monitoring using the same equipment. Other examples of transmission include use of finger-stick devices for several patients in succession when the devices are designed for single-patient use, or when surgical equipment is inadequately sterilized between patients.

For more information on preventing hepatitis B infection, visit the Web resources listed on this page. We appreciate your efforts to keep patients with diabetes healthy and safe, including ensuring their protection against hepatitis B and other vaccine-preventable diseases. Thank you for watching.

Web Resources

Centers for Disease Control and Prevention. Infection Prevention during Blood Glucose Monitoring and Insulin Administration.

Centers for Disease Control and Prevention. Diabetes and Viral Hepatitis: Important Information on Glucose Monitoring.

Use of Hepatitis B Vaccination for Adults with Diabetes Mellitus: Recommendations of the Advisory Committee on Immunization Practices (ACIP)

Dr. Trudy Murphy is the Vaccine Unit Team Lead for the Division of Viral Hepatitis at the Centers for Disease Control and Prevention in Atlanta, Georgia. Dr. Murphy entered the field of public health after a number of years on the Pediatric and Pediatric Infectious Diseases faculty at the University of Texas Southwestern Medical Center. She has authored or coauthored more than 120 peer-reviewed journal articles, Morbidity and Mortality Weekly Report articles, and book chapters. At CDC, she has been active in vaccine research and policy development for vaccine-preventable diseases, most recently for prevention of hepatitis A and hepatitis B.

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