Hepatitis B Vaccines: Reviewing ACIP Recommendations, Series Options

Brett Lown, PharmD, medical science liaison, Dynavax, reviews CDC recommendations for hepatitis B vaccination, as well as how pharmacists can ensure patients become fully immunized.

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

In this episode, Dr Brett Lown reviews hepatitis B vaccine recommendations and tips to ensure patients are fully immunized.

Thank you, Maria. I appreciate you having me on here. My name is Brett Lown and I am the medical science liaison for Dynavax Technologies.

I have a doctorate pharmacy degree and roughly 20 years of experience in retail pharmacy. I've worked as a pharmacist for Rite Aid and Walgreens pharmacies for roughly 13 of those years. Prior to that, I was an intern and technician as well. I worked there until November 2021. I also spent a short period of time working in managed care for Blue Cross Blue Shield of North Carolina as a clinical review pharmacist.

How prevalent is hepatitis B and what is the associated symptom burden?

Before I jump into prevalence, I'll briefly talk about the virus. Hepatitis B virus is roughly 100 times more infectious than HIV. We know it is spread through contact with infected blood or bodily fluids. It’s also quite a hearty virus, so it can remain infectious at room temperature outside of the body for up to about 1 week and it doesn't have to remain in visible blood. It’s quite infectious even outside the body.

Globally, roughly 257 million persons are chronically infected. Roughly 12 million Americans have evidence of acute infection at some point, whether that be current or previous, and roughly 2.5 million of those Americans are living with chronic infection.

To put that number in perspective, it's estimated that 1.2 million persons in the United States are living with HIV, so roughly twice as many people have hepatitis B virus in this country. Not diminishing HIV, of course, but just to put that number into perspective.

Unfortunately, roughly 80% of those chronically infected are unaware that they're infected. Individuals who are chronically infected are the main reservoir of transmission, and those who are unaware are much more likely to spread the infection. If you're sharing a razor or toothbrush, or if you're having unprotected sex with somebody who's chronically infected and does not know they have it, it's a lot easier to contract it.

Hepatitis B virus contributes to a high health care burden in this country as well. A conservative estimate indicates we spend almost 1 billion dollars annually on hepatitis B-related hospitalizations. Acute infections can cause anything from liver failure to hospitalization. Chronic infections can lead to cirrhosis or hepatocellular carcinoma, aka liver cancer, which can cause liver failure.

Unfortunately, 25% of individuals who are chronically infected will die prematurely because of these complications.

Can you review the current CDC recommendation for hepatitis B vaccination in adults?

Yes, absolutely. I'll touch on some background as to why the CDC implemented these new recommendations.

The federal government has set a goal to eliminate by viral hepatitis by the year 2030. There has been an increase in infection for certain adult populations aged over 40 years, because those age groups are not routinely vaccinated. We also know that some states have had a significant increase in the number of acute infections due to the opioid epidemic in this country.

Additionally, previous ACIP recommendations for hepatitis B were risk-based and have unfortunately fallen short. Risk-based recommendations emphasized the patient coming in to request hepatitis B vaccination based on their associated risks, and a lot of these risks were stigmatizing or incriminating behaviors.

In a survey of people who are acutely infected, only one-third of those patients had an identified risk factor. In other words, the other two-thirds did not disclose, or it was unknown. While we have effective vaccination to prevent this disease, up to 75% of adults are unvaccinated against hepatitis B.

Jumping to the new recommendations, the ACIP recently simplified and expanded them. These recommendations were voted on back in the fall and have been updated in the Morbidity and Mortality Weekly Report and the new ACIP vaccine schedule for adults.

The new recommendations state all adults aged 19 to 59 years should be vaccinated against hepatitis B. Adults aged 60 years and older with risk factors should also be vaccinated against hepatitis B. Adults aged 60 years and older without known risk factors may be vaccinated against hepatitis B. The catchall there is that anybody 60 years of age and older that doesn't have a risk factor can still be vaccinated against it.

We know that age-based recommendations tend to work better. They're much more simplified. Thinking back to my days as a pharmacist when I'd be recommending vaccines, this emphasizes hepatitis B vaccination with how we identify older adults for vaccine-preventable diseases. If an adult walks in and we know they're 65 years of age and older, we recommend their pneumococcal vaccine. Or if they're 50 years of age and older, we recommend their shingles vaccine. Now, when an adult that's 19 years of age and older comes to the pharmacy, we can recommend their hepatitis B vaccine.

We can even make it a step further and simplify it. In 1991, they issued a universal recommendation for hepatitis B in all infants. If you see anybody born before 1991 in the United States, you can just recommend hepatitis B vaccination. Again, though, you can also stick to that 19 years of age and older benchmark.

For vaccines for adults, there are 3-dose options. They're administered at 0, 1, and 6 months, commonly known Engerix or Recombivax. Those are probably the two more common ones there. There's also a 2-dose option known as Heplisav-B. This is given as 2 doses over 1 month, so this allows you to protect your patients much more quickly and has a higher likelihood of series completion.

We haven't talked about series completion either, but I would like to make a couple points on that. To start, series completion is crucial, as we know with COVID-19 vaccines, right? If you only get the first dose you're not fully vaccinated. Most patients who don’t complete their series won't be protected.

Additionally, the fewer number of doses, the easier it is to complete the series. It's a lot easier to follow a patient over 1 month, where they might return to the pharmacy in 30 days anyway to get their refill of a prescription, and you can just recommend that second dose after that 30-day period.

I saw a lot of patients not receive a complete vaccine series as a pharmacist—myself included, unfortunately, for my hepatitis B vaccines. I did receive the first 2 doses, and I forgot the third dose because of that 5-month gap between the second and third doses. It took me about a year and a half to return and get that vaccine, which left me unprotected while vaccinating patients and being exposed to potentially infectious blood during that time period.

As a pharmacist, I know the risks. I'm well aware that I need to complete the series. I still forgot my third dose. So it certainly happens. We have numbers that show roughly 77% of patients that initiate a 3-dose series don't return to get the final dose. You're twice as likely to complete a 2-dose series compared to a 3-dose series.

What are some other barriers to hepatitis B vaccine access?

Actually, we have some good news. With these new ACIP recommendations and certain coverage requirements outlined by the Affordable Care Act, insurers are required to reimburse all FDA-approved vaccines. There shouldn't be any barriers to cost or access.

How do you think pharmacists can help improve access to vaccines?

The new recommendations are designed to have the health care provider or, in our case, the pharmacist, offer to vaccinate a patient rather than have the patient request the vaccine. In other words, again, we can offer to vaccinate patients aged 19 years and older. Unless they can present a documented vaccine series completion, that patient should be vaccinated against hepatitis B per the recommendations outlined recently by the CDC.

Putting my pharmacist hat on and thinking back to when I was practicing, we can also get our technicians involved in this. I would hold a meeting. The nice thing about this recommendation is it’s simple, and your technicians are usually the first point of contact anyway. They can see that date of birth when the patient comes to pick up their prescription.

The risk associated with hepatitis B virus and these new recommendations are a simple conversation to have, and technicians can implement that at the point of sale. Knowing what vaccine options are available is important too. It's easier for that technician to follow a patient for that month to make sure they come back and get that 2-dose series.

We can also make it easier on ourselves. Hepatitis B vaccines can be administered with other vaccines as well. If we're already vaccinating a patient, as long as it's in a different anatomical site, we can add the hepatitis B vaccine.

I know all health care providers are stretched a little thin right now, but we can start simple, right? As long as we're having that conversation, making people understand they should be vaccinated against hepatitis B, certainly in that group aged 19 to 59 years. If a patient is getting their COVID-19 vaccine, you can add a hepatitis B vaccine to that. A lot of ancillary vaccines are done in the spring and summer, like pneumonia and shingles, and you can add it to that as well.

A recent study I read evaluated those patients that were closely followed by a pharmacist for multidose vaccines. Patients had a significantly higher completion rate than those that were not followed by a pharmacist. In other words, we can really make an impact.

Additionally, there's no maximum interval for these vaccines. We can catch individuals who may have only received two of their 3-dose series. We can make that recommendation and have those individuals complete that series and be protected as well.

Thank you, Dr Lown. That's it for the big questions. Is there anything else that we haven't covered that you wanted to add today?

I know pharmacists are flying a million miles an hour back there, and we're all stretched pretty thin. But a recent analysis showed 37.1 million doses of recommended vaccines have been missed by adults and adolescents during 1.5 years of the pandemic. To put that in perspective, for adults specifically, a survey done by the CDC showed 3 out of 4 adults are missing 1 or more routinely recommended vaccines.

It’s time to start thinking about other vaccine-preventable diseases. We can focus on hepatitis B. We have those new ACIP recommendations and that elimination goal for viral hepatitis by the year 2030.

These recommendations are simple. They're age based. We don't have to guess what risk factors a patient might have. We can just offer to vaccinate all these adults. We know how important it is to complete the series. And we know it's easier to complete a series with a 2-dose vaccine, so we can leverage that to try and meet that elimination goal as well.

Lastly, for anybody that wants more information, I encourage you to go to HeplisavBHCP.com.

Thanks for tuning in to another episode of PopHealth Perspectives. For similar content or to join our mailing list, visit populationhealthnet.com.

This transcript has been edited for clarity.