New Recommendations on Adult Hepatitis B Vaccination

Cindy Weinbaum, Stephanie M Neitzel, Eric E Mast, Karen A Hennessey
US Gastroenterology & Hepatology Review, 2008;4(2):21-23
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Hepatitis B vaccination is the most effective measure to prevent hepatitis B virus (HBV) infection and its consequences, including acute hepatitis B in persons newly infected with HBV and chronic liver disease (e.g. cirrhosis, liver cancer) in persons who develop chronic HBV infection. In the US, the incidence of new HBV infections has declined from 200,000–300,000 per year in the 1980s to approximately 51,000 in 2005 as a result of the implementation of a comprehensive immunization strategy to eliminate HBV transmission, which was first recommended by the Advisory Committee on Immunization Practices (ACIP) in 1991.1,2 Components of this strategy include universal infant hepatitis B vaccination from birth, prevention of peri-natal HBV transmission by screening all pregnant women for hepatitis B surface antigen (HBsAg) and providing immunoprophylaxis to infants born to HBsAg-positive women, vaccination of previously unvaccinated children and adolescents, and vaccination of adults at risk for HBV infection.

To date, hepatitis B immunization strategies for infants, children, and adolescents have been implemented with considerable success.2,3 However, vaccination of adults has proved more difficult. Guidelines for vaccinating adults against hepatitis B, first published in 1982, have recommended targeting vaccination at populations with defined risk factors for HBV infection, including household contacts and sex partners of HBV-infected persons, persons with multiple sex partners, men who have sex with men (MSM), injection-drug users (IDUs), inmates of correctional facilities, healthcare workers and others with occupational risks for blood exposures, travelers to HBV-endemic regions, clients and staff of institutions for developmentally disabled persons, hemodialysis patients, and recipients of certain blood products.4 Despite these risk-based recommendations, vaccination coverage among adults with behavioral risk factors for HBV infection remains low, and the incidence of acute hepatitis B in the US remains highest among adults. To address this critical gap in hepatitis B prevention, ACIP published updated recommendations for adult hepatitis B vaccination in December 2006.5 The purpose of this article is to provide an overview of the new recommendations, which emphasize not only who to vaccinate but also how to vaccinate, providing venue-specific vaccination strategies to reach large numbers of adults at risk.

Epidemiology of Hepatitis B Virus Infection
HBV is transmitted through percutaneous (i.e. puncture through the skin) or mucosal (i.e. direct contact with mucous membranes) exposure to infectious blood or body fluids. HBV infection can be acute, ranging from asymptomatic infection to icteric hepatitis and, in rare cases, fulminant hepatitis and death. In some persons, HBV infection becomes chronic, which can result in cirrhosis of the liver, hepatocellular carcinoma, liver failure, and death. Although chronic infection is more likely to develop when infection occurs during infancy or early childhood, rates of new infection and acute disease are highest among adults.

In the US in 2005, the incidence of acute hepatitis B was highest among adults 25–45 years of age.2 HBV infection in adults occurs primarily among unvaccinated persons with behavioral risks (e.g. heterosexuals with multiple sex partners, IDUs, and MSM) and among household contacts and sex partners of persons with chronic HBV infection. Among cases reported in the Sentinel Counties Study of Viral Hepatitis (SCSVH) of the Centers for Disease Control and Prevention (CDC) during 2001–2005, nearly 80% of newly acquired cases of hepatitis B were associated with high-risk sexual activity (39% attributable to heterosexual transmission and 24% attributable to sexual transmission among MSM) or injection-drug use (16%) (CDC, unpublished data, 2001–2005). Those living with chronically infected persons are also at risk for HBV infection through percutaneous or mucosal exposure to blood or infectious body fluids (e.g. sharing toothbrushes or razors, contact with exudates from dermatological lesions, or contact with HBsAg-contaminated surfaces).

Public health measures have resulted in notable reductions in healthcareassociated HBV transmission. Before the widespread implementation of hepatitis B vaccination, HBV infection was a common occupational hazard among persons exposed to blood while caring for patients or working in laboratories. However, routine vaccination of healthcare workers and use of standard precautions to prevent exposure to bloodborne pathogens have resulted in HBV infection being a rare event in these populations.5 Likewise, stringent donor selection procedures and routine testing of donors in the US have made transmission of HBV via transfusion rare.6 In addition, persons with hemophilia who received plasma-derived clotting factor concentrate were previously at high risk for HBV infection, but use of viral inactivation procedures and recombinant clotting factor concentrates have eliminated HBV transmission attributable to blood products among this population.7

References:
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