Published online Jan 27, 2019. doi: 10.4254/wjh.v11.i1.86
Peer-review started: September 6, 2018
First decision: November 14, 2018
Revised: November 27, 2018
Accepted: January 9, 2019
Article in press: January 9, 2019
Published online: January 27, 2019
Hepatitis B is a liver infection caused by the hepatitis B virus (HBV), affecting 1.4 million people in the United States, and 350 people worldwide. HBV infection accounts annually for 4000 to 5500 deaths in the United States and 1 million deaths worldwide from cirrhosis, liver failure, and hepatocellular carcinoma (HCC). Hepatitis B vaccination is 95% effective in preventing infection and the development of chronic disease and liver cancer due to hepatitis B in adults vaccinated before being exposed to the virus. Hepatitis B disproportionately affects certain high-risk populations. HBV vaccination coverage in high-risk individuals in the United States was reported to be around 42% in 2012. The Centers for Disease Control (CDC) recommends all individuals at high-risk for HBV infection undergo vaccination. These guidelines expanded in 2011 to include those with diabetes mellitus (DM). The purpose of our study is to evaluate clinical factors associated with HBV screening and vaccination in high-risk individuals.
Hepatitis B infection is a significant cause of liver disease in the United States. With the advent of HBV vaccination, rates of hepatitis B infection have declined, but the rates of vaccination in high-risk individuals have not significantly increased over previous years. With the recommendation for expanded HBV vaccination guidelines from the CDC, current rates in high-risk individuals may be underestimated. Our research study looks to evaluate clinical factors associated with HBV screening and vaccination in high-risk individuals, which may provide better understanding to the current vaccination rates in this population. Estimating current vaccination rates in high-risk individuals is important for future research that can study different methods to improving vaccination rates.
The main objective of this study was to evaluate screening and vaccination rates in high-risk individuals, and clinical factors associated with screening and vaccination. We found that the vaccination rates in high-risk individuals remains low in our study population, and that these rates are similar to previous national rates despite updated CDC guidelines.
We conducted a retrospective review of 999 patients presenting at a large urban healthcare system from 2012-2017 at high-risk for hepatitis B infection. Patients were considered high-risk for hepatitis B infection based on hepatitis B practice recommendations from the Centers for Disease Control. Medical history including hepatitis B serology, medical diagnoses, demographics, insurance status and social history were extracted from electronic health records. Multivariate logistic regression was used to identify clinical risk factors independently associated with hepatitis B screening and vaccination.
Among the 999 patients, 556 (55.7%) patients were screened for hepatitis B. Of those who were screened, only 242 (43.5%) patients were vaccinated against hepatitis B. Multivariate regression analysis revealed end-stage renal disease (ESRD) [odds ratio (OR): 5.122; 2.766-9.483], alcoholic hepatitis (OR: 3.064; 1.020-9.206), and cirrhosis or end-stage liver disease (OR: 1.909; 1.095-3.329; all P < 0.05) were associated with hepatitis B screening, while increasing age (OR: 0.785; 0.680-0.906), insurance status (0.690; 0.558-0.854), history of DM (OR: 0.518; 0.364-0.737), and human immunodeficiency virus (OR: 0.443; 0.273-0.718; all P < 0.05) were less likely to undergo hepatitis B screening. Of adults vaccinated for hepatitis B, multivariate regression analysis revealed increasing age (OR: 0.755; 0.650-0.878), BMI (0.799; 0.671-0.952), and DM (OR: 0.620; 0.409-0.941; all P < 0.05) were less likely to undergo hepatitis B vaccination.
Vaccination rates in high-risk individuals remain low at 43.5% in our study and ways to improve these rates need to be evaluated. The CDC recommends all individuals at high-risk for HBV infection undergo vaccination. Our study reveals that patients at high-risk for hepatitis B are not being adequately screened and/or vaccinated. With the addition of DM in the CDC HBV vaccination guidelines, we found that older age, diabetes, and decreasing insurance coverage were associated with a lower likelihood of being screened or vaccinated for HBV, while ESRD was associated with increased likelihood of screening. Vaccination rates likely remain low due to lack of knowledge by patients and physicians on appropriate implementation of CDC guidelines. Identifying patients who are at high-risk for infection is an important step in decreasing the incidence (and ultimately the prevalence) of HBV infections in the United States. Future studies are needed to further identify and improve ways to improve HBV vaccinations, particularly in high-risk patients.
Identifying high-risk patients who are likely to benefit from further review of their HBV vaccination status and implementation of vaccination to those in need is of high importance in the prevention of hepatitis B infection and its sequelae including chronic liver disease, cirrhosis and HCC. Despite CDC recommendations, HBV vaccination rates in high-risk individuals are still not optimal. The direction of future research should be aimed at obtaining national rates to better gauge vaccination in the United States. Also, with the knowledge of current vaccinations rates, future studies can evaluate different modalities including patient and physician education, immunization registries, reminder-recall systems and provider prompts that can help improve HBV management.