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HBV: Vaccine Underutilization
The Underutilization of HBV Vaccines in Adults

Released: February 22, 2022

Expiration: February 21, 2023

Judith Feinberg
Judith Feinberg, MD
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Many people who were born before 1992 in the United States are vulnerable to hepatitis B infection. It was not until 1992 that the US Center for Public Health Practice recommended vaccinating newborns, starting with the first dose of the hepatitis B vaccine before hospital discharge. This recommendation provided sufficient protection for individuals who were born in the United States in 1992 and thereafter.

Before then, the guidelines focused on gay men, injection drug users, healthcare workers, and children of women with hepatitis B. Giving the first vaccine dose to babies shortly after birth in the hospital ushered in an era of near-universal vaccination for hepatitis B. But we still have some catching up to do.

Hepatitis B can be acquired through sexual contact, sharing syringes to inject drugs, blood-rich environments such as hemodialysis centers, or mother-to-child transmission. Furthermore, hepatitis B infection puts people at risk for the development of chronic hepatitis B, which can lead to liver fibrosis, cirrhosis, and hepatocellular carcinoma. This is why hepatitis B should be a concern for the unvaccinated.

Underutilization of HBV Vaccines
The optimal approach for preventing hepatitis B is through vaccination. In the past, to be fully protected against hepatitis B, 3 vaccine doses containing a single hepatitis B antigen had to be administered on a 6-month schedule. This timeframe was a challenge for some and many people did not complete the series.

Recently, 2 newer hepatitis B vaccines were approved by the FDA for use in adults. The vaccine approved in 2017, is a 2-dose series administered over 1 month and it includes an immune adjuvant to improve immunogenicity. I expect it may improve hepatitis B vaccine completion rates as fewer patients will be lost to follow up. The second vaccine, approved in 2021, is the first hepatitis B vaccine to contain 3 hepatitis B antigens and the 3-dose series is administered over 6 months. The phase III PROTECT trial showed the vaccine to be non-inferior to the older single-antigen formulation in adults aged 18 years and older and superior in adults aged 45 years or older. This vaccine also provided better seroprotection after the second and third doses. Both of these newer vaccines result in higher antibody titers than the older, single-antigen vaccines.

Awareness and Screening in the Clinic
Where I practice, in West Virginia, we have had the highest rate of acute hepatitis B in the nation for over a decade. The acquisition of hepatitis B is very much tied to the injection drug epidemic. While we need to provide hepatitis B vaccination in doctors’ offices and health departments, we also need to learn how better to reach people who inject drugs (PWID) to offer hepatitis B protection. Since many PWID have chronic hepatitis C, their risk of acquiring acute hepatitis and subsequent liver damage is increased. Moreover, many PWID have high rates of new hepatitis B infections.

When reviewing vaccine records, healthcare providers should ensure that their patients are up to date with all vaccines according to current Centers for Disease Control and Prevention/Advisory Committee on Immunization Practices (CDC/ACIP) recommendations, including the hepatitis B vaccine. The workflow for patient appointments should include reviewing and updating the patient’s vaccination record.

While hepatitis B screening and vaccination should be done universally, the urgency and emphasis of the vaccine recommendation from healthcare providers can vary. A different degree of urgency is required if a healthcare provider examines a patient with scarring at injection sites or if they disclose their drug use. Additionally, there is an enhanced risk for severe liver damage if a patient already has chronic hepatitis C. Although everyone should be vaccinated, my recommendation for vaccination is much stronger for individuals who are at a greater risk for acquiring hepatitis B.

Your Thoughts?
What is your experience with recommending or providing hepatitis B vaccination in vulnerable patients? Take part in our poll or share your comments with other readers in the discussion section below.

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Which of the following are the most important factors for improving access to HBV vaccination? Check all that apply
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