Age, Geography Predict COVID-19 Vaccination of Vets With Cirrhosis

Neil Osterweil

November 16, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Vaccination against SARS-CoV-2 infection can protect patients with liver cirrhosis from decompensation, hospitalization, and death, but getting those patients to accept vaccination can be challenging.

A retrospective study was conducted regarding the factors associated with failure of patients with cirrhosis in the Veterans Health Administration (VHA) system to get vaccinated against COVID-19. Only 60% of patients with cirrhosis had been vaccinated.

Those least likely to be vaccinated were younger, White, current smokers, and lived in rural areas, especially in the South, said Sara Chapin, MD, a second-year internal medicine resident at the Hospital of the University of Pennsylvania, in Philadelphia, during a presentation of the findings at The Liver Meeting 2021: American Association for the Study of Liver Diseases (AASLD), held online.

"Moving forward, I feel ultimately that it's our duty as physicians caring for a vulnerable patient population to educate and encourage vaccination, but we also have to work to create new and innovative approaches to improve vaccination rates," she said.

Chapin said that one method for improving vaccination rates among these patients would be to issue a mandate requiring patients on liver transplant waiting lists to be vaccinated against COVID-19.

Variables Associated With Lack of Vaccination

Chapin and colleagues evaluated data on adults aged 18 years and older with cirrhosis who were actively followed in the VHA system. Patients who had previously received a liver transplant were excluded.

The investigators identified a total of 43,122 patients with cirrhosis. These patients were followed from December 18, 2020, when the VHA began its vaccination campaign, through the data cutoff date of June 15, 2021.

The median age of the patients was 67 years, 96% were men, and 61.3% were White.

Hepatitis C virus infection, alcohol-related liver disease, and nonalcoholic fatty liver disease each accounted for approximately one third of cases.

In all, nearly two thirds of patients (62.8%) were current or former smokers.

The largest proportion of patients lived in the South (46.5%), followed by the West (22.2%), the Midwest (18.6%), and the Northeast (12.7%).

A total of 25,875 patients (60%) had received at least one dose of a COVID-19 vaccine by the cutoff date. Most received an mRNA-based vaccine (Pfizer-BioNTech or Moderna); a smaller proportion received the viral vector–based vaccine (Johnson & Johnson).

The majority of the vaccinations occurred in the early months of the campaign, from January 2021 through March 2021. There was a steep drop-off at the beginning of spring.

In a multivariable analysis that controlled for demographics, comorbidities, and geographic factors, the investigators found that the factors positively associated with vaccination included increasing age, diabetes, hypertension, coronary artery disease, decompensated cirrhosis, Black race, and Hispanic ethnicity.

In contrast, factors negatively associated with vaccination included higher Model for End-Stage Liver Disease (MELD) scores, current smoking, and residence in the South and in a rural location.

Factors significantly predictive of a low probability (<50%) of being vaccinated included younger age (median, 56 years, vs 72 years for high probability), White (80.8%, vs 41.4% for high probability), current smoking (48.8%, vs 11.5% for high probability), and residence in the South (70.4%, vs 4.2% for high probability; P < .001 for all comparisons).

Patients with a low probability of vaccination were also significantly less likely to have comorbidities, such as diabetes, congestive heart failure, or coronary artery disease, the investigators found.

Commenting for Medscape Medical News, Robert J. Fontana, MD, FAASLD, professor of medicine and director of the transplant hepatology fellowship program at the University of Michigan, in Ann Arbor, said that the data are not especially surprising and appear to reflect national trends in COVID-19 vaccine uptake.

"I've been involved with the COVID AASLD Task Force, and we've been trying to promote knowledge and dispel some of the myths about the vaccine," he said.

"When I looked at this data, what I could have extracted from it is that younger people with fewer problems tend to feel ― the word 'invincible' is a little too strong ― but they tend to feel that, 'It's not for me, I'm OK.' "

He noted that about 96% of the VHA population is male, and male veterans are more likely to have a tough, stoic attitude about their health.

"I'm pretty sure that the same findings are in the general population as well," he said.

Why Vaccination Matters

In a separate study presented in the same session, Binu V. John, MD, MPH, chief of hepatology at the Bruce W. Carter VA Medical Center, in Miami, Florida, reported that among patients with cirrhosis, there was a 64.8% reduction in SARS-CoV-2 infections and 100% protection against hospitalization or death due to COVID-19 28 days after the first dose of an mRNA vaccine compared with unvaccinated patients with cirrhosis.

The association of reduced SARS-CoV-2 infections after the first dose was lower among patients with decompensated cirrhosis compared to those with compensated cirrhosis, the authors found.

Also during that session, Luis Diaz Piga, MD, from Pontificia Universidad Católica de Chile, in Santiago, Chile, reported that among patients with cirrhosis who were fully vaccinated, the rate of hospitalization was 12.69% lower than among unvaccinated patients with cirrhosis.

Although the protective effect of the vaccine was seen in patients with heart failure, diabetes, hypertension, and asthma, it was strongest for patients with cirrhosis, he said.

The study by Chapin and colleagues was funded by the American College of Gastroenterology. Chapin, Fontana, John, and Diaz Piga have reported no relevant financial relationships.

The Liver Meeting 2021: American Association for the Study of Liver Diseases (AASLD): Abstract 37, Abstract 38, and Abstract 39. Presented November 13, 2021.

Neil Osterweil, an award-winning medical journalist, is a long-standing and frequent contributor to Medscape.

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