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.
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