A Public Health Dream–Hepatitis B Vaccines For All

by Marisa Mead on February 8, 2012

Electron micrograph of hepatitis B virus*

Public health efforts have led to many victories: eradicating smallpox through vaccination, preventing tooth decay by fluoridating drinking water, and saving lives with car seatbelt laws, among others. Many of the noteworthy public health achievements apply to all members of a community regardless of factors such as income, race, age, or gender.

Eradication of hepatitis B, a liver disease caused by a virus, has the potential to be included in that list of noteworthy public health achievements. A vaccine was developed in 1982, and since then the rate of infection in the US has decreased by 82% because of persistent efforts to routinely vaccinate infants, children, and adolescents. Hepatitis B is far from eradication, however.

High Risk Groups

The CDC estimates that 1.4 million people in the US are infected with hepatitis B, and 40,000 new cases of infection occur each year. There has been little progress in increasing hepatitis B vaccine coverage in adults who participate in behavior that put them at risk for contracting the virus. High-risk groups include men who have sex with men, sex partners of infected persons, individuals with multiple sex partners, and injection drug users. These groups combined account for more than 75% of new infections each year. Additionally, over 70% of these newly infected individuals had opportunities to become vaccinated (through contact with health care providers or in prisons), but did not.

A study by Farah Ladak and colleagues at Brown University identified factors among high-risk individuals which are associated with a higher probability of being vaccinated. In identifying these predictors, the authors also highlight important opportunities to improve vaccination coverage. The authors analyzed responses from over 15,000 high-risk individuals from the 2007 Behavioral Risk Factor Surveillance Survey (BRFSS) conducted by the CDC. Their analysis found that the majority (56%) of high-risk individuals were not vaccinated against hepatitis B. In particular, adults over 33 were less likely to be vaccinated than younger adults. This reflects US policy amendments in the early 1990s which universalized hepatitis B vaccination at birth. Children are always an important group considered for vaccinations, but should public health systems be responsible for ensuring at-risk adults are protected against infection as well?

Respondents in the survey who previously received flu or pneumonia vaccines were more likely to be vaccinated against hepatitis B compared with individuals who were not vaccinated against either influenza or pneumonia. The authors posit that could be because patients who received flu/pneumonia vaccines are aware of the importance of vaccines in disease prevention and were therefore more likely to get a hepatitis B vaccine as well.

Having health insurance also increased the likelihood of being vaccinated against hepatitis B. This is not surprising considering each dose of the hepatitis B vaccine (three are needed for a complete vaccine) can cost up to $100.00. Low allocation of federal public funds for the purchase of adult vaccinations could be to blame. And although individuals with Medicaid can get vaccinated at $0.50-$6.00 per shot, strict eligibility criteria for Medicaid insurance can prevent high-risk individuals from benefiting from subsidized vaccinations.

Missed Opportunities

Finally, the study draws attention to missed opportunities for hepatitis B vaccination in places frequented by high-risk adults, such as HIV testing and counseling clinics, drug treatment facilities, and prisons and jails. Respondents of the study who had been tested for HIV at a doctor’s office, HMO, hospital or clinic were more likely to be vaccinated against hepatitis B than those who were tested in jail or prison, or not tested for HIV at all. The 2010 Institute of Medicine (IOM) report recommends capitalizing on situations when at-risk individuals come in contact with health care providers by offering vaccinations in places frequented by high-risk groups: prisons and jails, STD clinics, and drug treatment centers.

Not surprisingly, the IOM also recommends additional government funding for hepatitis B vaccination of at-risk adults. Hepatitis B and C are not thought of as serious public health concerns in the US, and in turn there is a lack of funding for surveillance, prevention, and treatment of the diseases. Yet, hepatitis diseases are more common than HIV/AIDS in the US. In many cases, hepatitis B goes undiagnosed for a long time, because symptoms may not appear until the patient develops liver cancer. New cases will continue to arise, disproportionately so in at-risk adults, unless they are protected through vaccination.

In 2002, cost-benefit analysis by the CDC estimated about $45 million in savings to the health care system over 20 years if all new inmates serving more than one year were vaccinated against hepatitis B. Research at the University of Cincinnati has provided evidence that prevention, screening, and treatment for hepatitis B, even in populations where less than 2% are affected, is also cost effective. The technology for preventing hepatitis B is available, but resources are not allocated properly. Until then, eradication of hepatitis B (in the US—globally is a whole separate issue which I will not discuss here) is just another item on the bottom of public health’s “to-do” list.

Reference for the study:

F. Ladak, A. Gjelsvik, E. Feller, S. Rosenthal and B. T. Montague. Hepatitis B in the United States: ongoing missed opportunities for hepatitis B vaccination, evidence from the Behavioral Risk Factor Surveillance Survey, 2007. Infection. January 12, 2012.

*Main photo by CDC [Public domain], via Wikimedia Commons

Andrea Learned February 8, 2012 at 12:31 pm

This is interesting research, though I think there may be opportunity to shorten the piece a bit and make it seem more applicable to the lay audience/give it more personality. For example, the tone/comment of the last sentence could be a way to gear the entire piece…shape it into something more casually readable.

Marisa Mead February 8, 2012 at 4:24 pm

Thanks for you feedback Andrea, I’d certainly like my posts to have more personality!

Robyn Sussel February 8, 2012 at 3:44 pm

Yes, the research is well presented but it’s kind of dry. And bit too high level for the readership. I would try to take more of a story telling approach to this. Maybe start with a story about the intense health care utilization of someone with Hep B and then move to the more macro numbers related to the study.

Marisa Mead February 8, 2012 at 4:28 pm

Thank you Robyn, I’ll take that into consideration for my next post!

Patricia February 8, 2012 at 11:54 pm

I also agree. A little too technical for general public, which can demerit your post. Also, as an advice, since in a blog you don’t have to pay for cor prints, try putting a color image that can be more appealing to the public. Tje image you cose is not clear to the grneral public, you have to know what it represents.

Marisa Mead February 9, 2012 at 6:28 pm

Thanks Patricia, this week I tried putting more information in my post since in past weeks I’ve gotten comments that I should add more, but it didn’t turn out quite as I intended. As always, I will work on it for the next post.

Lisa Razzi February 9, 2012 at 4:11 pm

Perhaps one interesting angle would have been to discuss the issue of vaccinating against an STD in the context of the current debate about HPV vaccinations. This may feel overly controversial, but HPV vaccines have been in the news lately (especially in VA) so I feel like the average reader might pick up on that as something they are more familiar with. Also, the Hep B vaccination campaign has been comparatively successful, so it might be interesting to consider why. Just a thought, and something I’ve been curious about, personally.

Marisa Mead February 9, 2012 at 10:26 pm

Hm, you make an interesting point at how the hep B vaccine campaign was way more successful than HPV. Now I’m curious as to why that is too!

While that’s a great topic that could be discussed, I also think that there is still more work to be done with the hep B vaccine. It was very successful, but for some reason the high-risk groups still aren’t getting the attention they deserve. Especially since hep B vaccine campaigns targeting high-risk groups aren’t unreasonable, it seems unfortunate those people are getting left behind. Even though they are a small group, it doesn’t make sense to ignore their health. That was the idea I was trying to get across in my article.

Drew Heyding February 10, 2012 at 9:47 am

I definitely agree that while we made great strides with childhood HBV vaccination coverage, the high risk groups you focus on are being left behind to a certain degree. I found it especially interesting to think about vaccination rates among those who are incarcerated. The 0.6 OR for HIV testing in jail (even if the CI included 1) stood out to me. Access to health care is typically not an issue in jails or prisons. Maybe it’s a resource / economic issue (i.e. funds are available for HIV testing and this public health is a priority but no money is there for HBV vaccinations).

David Hutton February 9, 2012 at 4:36 pm

I agree with Andrea that it might make sense to refocus this on the low priority that this disease has in the US. I think it’s good that you have a section on High Risk groups. You might want to also mention first and second-generation Americans from areas of the world with high prevalence. I’m also not sure you want to mention eradication: since chronic hepatitis B infection lasts a lifetime, the disease will probably not be eradicated in our lifetimes. With that said, I still think this is an important issue and you could say more about the high burden of this disease for those who have it.

Marisa Mead February 9, 2012 at 6:25 pm

Thanks for you feedback David. The disease is low priority in the US, but does that mean that high-risk groups should have to suffer from it more than others? I didn’t mention the high prevalence in immigrants because I was mainly focused on the high-risk populations in the US and wanted to highlight the lack of effort from our heath system to prevent hepatitis B in that group. But its good to realize that eradication is tough because of the first and second-generation Americans who also contribute to the disease’s prevalence. I agree, it won’t be eradicated in our lifetime, but it is an interesting idea since it is vaccine preventable and there are treatment options.

Anna February 10, 2012 at 12:23 pm

Marisa, you’ve shed some light on what be one of the most difficult challenges for health professionals. “70% of these newly infected individuals had opportunities to become vaccinated (through contact with health care providers or in prisons), but did not.”

Why do we do this to ourselves?! I think your blog shows the best path–target the efforts for those most at risk and where they are. That’s pretty much all society can do. People have to make that decision themselves.

Angela February 10, 2012 at 9:26 pm

I think there is wide-spread suspicion against some vaccines. They are believed to have variety of side effects. These may not necessarily be proven, but there is doubt nevertheless. I am pretty ambiguous about blaming people for not getting vaccines and mistrusting scientific research, although, obviously, there are potentially huge benefits in getting vaccinated.
When I still worked as a carer, I was supposed to have a Hep B jab, but refused it for two reasons. One: it was expensive: we had to pay for it ourselves, and, as carers, we received such bad wages that we could hardly pay our rent & we felt that the risk was negligible. Two: There were rumours about people getting MS after the vaccine. I did a little research and, apparently, there is no link between the two. I think it was Hep C? In any case, some of us were working with MS patients, and they warned us against any kind of hepatits vaccine, because they were convinced they got it from there, so most of us got pretty scared! Don’t know what the latest on the MS link is?

Mireio February 13, 2012 at 11:31 pm

Endless resources on the subject, and an ongoing battle of information. Considering represented agencies in the debate, and what’s at stake, thanks, but no thanks: I’ll pass on the vaccine. Three people I know contracted MS within a decade of being vaccinated, two of them blood related to me.
http://www.neurology.org/content/63/5/838.abstract

or google “hepatitis b vaccine multiple sclerosis”

Marisa Mead February 15, 2012 at 1:55 pm

Thanks for both of your replies. Misinformation and myths about vaccines are common. If you trust the CDC, you can find more info about that here: http://www.cdc.gov/vaccinesafety/Concerns/Index.html

Mireio, you highlight an important issue of research which I will try to avoid going into. Just because an article is published doesn’t mean that it’s good science or truth. I don’t have enough background in stats to analyze that study’s methods, but there were a couple responses to the Hernan article you linked which criticized its methods and conclusions. The overwhelming majority of research supports the fact that hep B does not cause MS (see the CDC link above), but I see how your situation and concern lead to your decision not to get vaccinated.

Marisa Mead February 15, 2012 at 1:43 pm

Thanks for your comment Anna. I’m not sure if it was clear or not, but the 70% that had “opportunities” to become vaccinated means that they were in a place that could have provided a vaccine, but did not get vaccinated because they were unaware that the vaccine was available to them or did not understand their risk for hep B. But you’re definitely right, the ultimate decision lies with the individual. The best we can do is provide them with enough information, which unfortunately is not the case currently.

Isobel Fritchey March 12, 2012 at 1:20 pm

Government within the U.S. today is often a senior partner in every business in the country.
If there is any situation that a male can perform well, I believe that let him take action. Provide him with a chance.

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