Hepatitis A vaccination Recommended For All Persons With Hepatitis B and Hepatitis C Virus

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Patients with HBV, HCV should receive hepatitis A vaccination
May 9, 2018
Physicians should consider administering hepatitis A vaccines to their patients with hepatitis B and those with hepatitis C, according to a…

Commentary

Need for Increasing Hepatitis A Virus Vaccination Among Patients Infected With Hepatitis B Virus and Hepatitis C Virus

Anne C. Moorman, Jian Xing, Noele P. Nelson For the CHeCS Investigators Centers for Disease Control and Prevention, Atlanta, Georgia

DOI: https://doi.org/10.1053/j.gastro.2018.04.031

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Severe morbidity can result from viral hepatitis co-infection, particularly in persons with existing chronic liver disease. Vaccination is the most effective way of preventing infection with the hepatitis A virus (HAV) and hepatitis B virus (HBV). Persons with chronic liver disease are currently recommended by the Advisory Committee on Immunization Practices to receive the HAV and HVB vaccines if they have not previously been vaccinated. Recently, the Advisory Committee on Immunization Practices approved language clarifying that all patients with hepatitis C virus (HCV) infection are recommended for HBV vaccination1 and that persons with HBV and HCV infections should also be specifically considered for vaccination against HAV.2, 3

Recent large outbreaks of HAV related to foodborne4, 5 and ongoing person-to-person exposures have resulted in substantial rates of morbidity and mortality5, 6, 7; these events underscored the relatively low prevalence of immunity against HAV infection among the US-born adult population.8 Poor HAV vaccine coverage among adults, combined with decreased childhood exposures to HAV since childhood vaccination initiation in 1996, have resulted in a low population immunity as measured by the prevalence of antibody to HAV (anti-HAV). Among adults age ≥18 years with chronic liver conditions participating in the 2014 and 2015 National Health Interview Survey, for example, only 19.4% reported having received 1 dose and 11.5% received 2 doses of HAV vaccine. Even among those with ≥10 provider visits, only 13.8% had received two doses of HAV vaccine, indicating missed opportunities for vaccination.9

The 1999 through 2012 National Health and Nutrition Examination Survey (NHANES) revealed that the overall anti-HAV prevalence among adults aged ≥20 years was about 25%.8 In the United States, immunity to HAV is greatest among the cohort of young people born after the 1996 recommendation for pediatric vaccination of children residing in areas of high transmission or incidence, particularly the cohort of children subject to the 2006 recommendation for universal pediatric HAV vaccination. Data from NHANES 2007 through 2012 showed 60% anti-HAV positivity among those aged 2 to 11 years in contrast with 16% to 18% among those aged 30 to 49. In earlier NHANES data from 1999 through 2006, only 21.4% of children aged 2 to 11 years had tested anti-HAV positive.8 Data from the National Immunization Survey—Child for 2012 through 2016 revealed that 82% of children 19 to 35 months had received ≥1 dose of vaccine in 2012, increasing incrementally each year to 86% in 2016.10 The increasing vaccine coverage and decreasing acute infection among children has resulted in reduced exposure to HAV for adults and consequently lower immunity among adults. This is exacerbated by poor vaccine coverage among adults, causing decreasing population immunity.

Recent data from the Chronic Hepatitis Cohort Study (CHeCS) at 4 large integrated US health care systems11 indicates that vaccination rates are far below desired public health goals. Among 3846 living chronic HBV-diagnosed and 15,471 HCV-diagnosed patients, results were available from total anti-HAV testing performed as part of routine clinical care and vaccination records from the electronic health record at any time in the patient’s past medical history through 2015. Updated vaccination records through 2016 were available for patients from 2 sites representing 35% of the cohorts. More than one-half of the HBV cohort patients had testing for anti-HAV and 60% were positive indicating immunity through either vaccination or past infection (Table 1). A similar proportion of HCV-infected patients had anti-HAV testing and 39% were positive. Among patients ever tested for anti-HAV in both HBV and HCV cohorts, significantly higher anti-HAV positivity was found among specific racial and ethnic groups. Higher numbers of patients of Asian/Pacific Islander and Hispanic race/ethnicity (70.3% and 56.3%, respectively) were immune to HAV compared with non-Hispanic black or white patients (37.7% and 38.4%, respectively; both P < .001). These differences could reflect exposure in early life among persons born in countries endemic for both HAV and HBV.

Continue to full-text article: https://www.gastrojournal.org/article/S0016-5085(18)34481-0/fulltext