The CDC Advisory Committee on Immunization Practices (ACIP) recently revised the recommendations for administration of the hepatitis B vaccine (Engerix-B—GlaxoSmithKline; Recombivax HB—Merck) to include adults with diabetes. ACIP used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, discussed on page 54 of the immunization section, as the basis for its recommendations.
ACIP recommended that all previously unvaccinated adults aged 19 years to 59 years with type 1 or 2 diabetes mellitus receive the hepatitis B vaccine series as soon as possible after their diagnosis (Category A recommendation). In addition, the committee recommended that administration of the hepatitis B vaccine series to patients with diabetes who are 60 years or older and who have not been previously vaccinated be done at the discretion of the clinician after assessing patient-specific risk factors and the likelihood of an adequate immune response (Category B recommendation).
These revisions were made after an assessment of data showing that patients with diabetes are at a greater risk of acquiring hepatitis B and having greater morbidity and mortality from the disease compared with those without diabetes.
Higher risk, greater mortality
In the December 23, 2011, issue of CDC’s Morbidity and Mortality Weekly Report, it was noted that since 1996, a total of 29 outbreaks of hepatitis B infection have been reported in one or more long-term care facilities such as nursing homes or assisted-living facilities. Of these outbreaks, 25 involved adults with diabetes who received assisted blood glucose monitoring.
CDC reported that an analysis of data from 865 confirmed cases of acute hepatitis B infection from eight Emerging Infectious Program (EIP) sites showed that persons aged 23 years to 59 years with diabetes who did not have any hepatitis B–related risk factors, such as injection drug use or multiple sexual partners, were 2.1 times more likely to develop hepatitis B compared with those without the disease. For adults 60 years and older, an analysis of the same data set revealed that these older patients were 1.5 times more likely to develop hepatitis B than their counterparts without diabetes.
Data spanning a decade from the National Health and Nutrition Examination Survey (1999–2010) confirmed these findings, with patients 18 years and older with diabetes having a 60% higher seroprevalence of antibody to hepatitis B core antigen compared with those without the disease.
Mortality data from EIP showed that patients with diabetes who were infected with hepatitis B had a higher case–fatality rate compared with those without diabetes (5% vs. 2%, P = 0.127). CDC noted that the progression of acute hepatitis B infection to chronic infection is greater in older adults with diabetes compared with otherwise healthy adults, and that the risk for chronic nonalcoholic liver disease and hepatocellular carcinoma is thought to be twice as high in patients with diabetes compared with those without diabetes.
Infection control precautions a must
Many of the outbreaks in this patient population have occurred as a result of percutaneous exposures to the hepatitis B virus from blood glucose devices shared among patients in inpatient settings.
Some of the issues noted by CDC included multipatient use of finger stick devices designed for single-patient use and inadequate disinfection and cleaning of blood glucose monitors between patients. The organization noted that education initiatives that promote greater attention to cleaning blood glucose monitors and avoiding the sharing of lancets or insulin needles are needed to improve infection control.
Patients with diabetes who have not been previously vaccinated against hepatitis B should be educated about the new ACIP recommendations and the importance of getting vaccinated. Inform patients that hepatitis B vaccinations are given as a three-dose series over a period of 6 months. ACIP strongly recommends hepatitis B vaccination for younger patients with diabetes (19–59 years), but the decision to vaccinate older patients should be made on an individual basis.
CDC noted that the antibody response to the hepatitis B vaccine series is reduced among older adults with diabetes. Data suggest that a protective response is achieved after completion of the series in more than 90% of patients with diabetes aged younger than 40 years of age, 80% of patients 41–59 years, 65% of patients 60–69 years, and less than 40% of patients older than 70 years. In addition, administration of the three-dose series in older patients has been shown to be less cost effective compared with younger patients.
CDC noted that the decision to vaccinate older adults with diabetes should incorporate the patients’ risks for acquiring the disease such as the need for blood glucose monitoring in a long-term care facility, the likelihood of experiencing chronic sequelae if infected, and the declining immunologic responses to vaccines that are common among frail, older adults. Pharmacists can bring up this topic in their discussions with patients with diabetes.