Why I Recommend Hepatitis B Vaccination to All My Patients

Sandra Adamson Fryhofer, MD


May 03, 2022

Editor’s Note: This report has been updated to reflect information on hepatitis B vaccines that became available after the video was recorded.

This transcript has been edited for clarity.

Hello. I'm Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic: the new hepatitis B vaccination recommendations for 2022. Here's why it matters.

Each year, more than 20,000 people in the United States contract acute hepatitis B, with healthcare costs of more than a billion dollars. As many as 40% of them have complications. Hepatitis B can lead to chronic hepatitis infection and liver cancer, and 15%-25% of those infected will die prematurely of cirrhosis or liver cancer. This is needless suffering and death.

Hepatitis B infection is vaccine preventable. We have several vaccine versions to choose from, and they work. The older, three-dose hepatitis B vaccine preparations are more than 90% protective. Immunity is durable, lasting at least three decades.

Two newer vaccines are now available, but only for those aged 18 or older. One of them, Heplisav, contains a new adjuvant, CpG 1018. Its two-dose series can be completed in just 1 month.

A new triple-target hepatitis B vaccine, PreHevbrio, was FDA-approved in December 2021. It requires three doses in a series and contains three hepatitis B antigens. Other available hepatitis B vaccines contain just one antigen. Like the older hepatitis B vaccines, the adjuvant used in PreHevbrio is aluminum hydroxide. Other hepatitis vaccines are yeast-based. PreHevbrio is grown in mammalian CHO cells. Study data for this triple-antigen version suggest high rates of seroprotection in adults, as well as immune response in key high-risk groups, including people with end-stage renal disease and HIV, and also in low and nonresponders.

The hepatitis B vaccine first became available in 1982. Since then, cases have dropped. Initial decreases in new infections plateaued 10 years ago. Rates are now highest in adults. Rates have also increased among adults aged 40 years or older. Racial and ethnic disparities remain. Current rates among Black American adults are now up to three times those of Asian, Pacific Islander, and Hispanic groups.

This year celebrates the 40th anniversary of hepatitis B vaccine recommendations in the United States. Previous recommendations for adults have been risk-based. Vaccine coverage within the indicated risk group shows that overall, vaccine uptake is lacking. Only two thirds of healthcare personnel have been vaccinated. Only about one third of those with chronic liver disease are fully vaccinated. Only about one third of adults under age 60 with diabetes have been vaccinated. If you look at who gets infected with hepatitis B, at least two thirds of the time no risk factor was identified or reported. Universal childhood hepatitis B vaccination has been a success. As a result, acute hepatitis B is on the path to complete elimination for those aged 29 years or older, but many older adults still remain unprotected. This led the Advisory Committee on Immunization Practices (ACIP) to consider whether all unvaccinated adults should receive hepatitis B vaccination.

Risk-based recommendations favor individuals with consistent access to preventive health services, as well as those who trust the system enough to disclose potentially stigmatizing risk factors. Risk-based recommendations also depend on awareness of risk for exposure to infected household contacts or infected sex partners. Health literacy also plays a role. We know from experience with other vaccines that universal, age-based recommendations lead to increased vaccine uptake as compared with those based on risk. Universal adult hepatitis B vaccination could decrease infections, prevent transmission, and reduce health disparities.

ACIP's Hepatitis B Workgroup Committee reviewed available data, and their preferred suggestion was for universal vaccination, meaning that all adults previously unvaccinated for hepatitis B should receive hepatitis B vaccination. There was no workgroup support for risk-based–only recommendations. However, the workgroup does not make the final recommendation; ACIP CDC's Independent Advisory Committee does.

ACIP did not accept the workgroup suggestion of universal hepatitis B vaccination on face value. Instead, ACIP voted and approved hepatitis B vaccine universally for those up to age 60. But for those aged 60 or older, the recommendation remains risk-based, with a loophole: Anyone aged 60 or older who wants it can get it. If you look at the risk indications, perhaps some may be uncomfortable or embarrassing to disclose, especially for older patients. The loophole sort of takes care of that, but patients still have to ask for the vaccine.

So if you get right down to it, in essence, in a roundabout way, we do now have a universal hepatitis B recommendation for all adults. Hepatitis B vaccination is clearly recommended universally for all adults up to age 60 — that's in the new recommendation — and adults aged 60 years or older who want it may receive it. I will certainly recommend it for all my patients.

For Medicine Matters. I'm Dr. Sandra Fryhofer.

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