A summary of presentations from the weekly Summit partner webinars
April 28, 2022 – The latest Summit summary
- Implementation Plan for Hepatitis B (CDC) – Noele Nelson (CDC)
- Implementation Plan for Hepatitis B (HHS) – Jessica Deerin (OIDP)
- Implementation Plan for Hepatitis B (Hepatitis B Foundation) – Michaela Jackson (Hepatitis B Foundation)
Implementation Plan for Hepatitis B (CDC) – Noele Nelson (CDC)
Noele Nelson, MD, PhD, MPH, Chief, Prevention Branch, Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD and TB Prevention, CDC, gave a presentation on the Implementation Plan for Hepatitis B from the CDC. VIEW PRESENTATION SLIDES.
In November 2021, ACIP voted unanimously to update the hepatitis B vaccination recommendations, which were published in MMWR on April 1, 2022. The new ACIP hepatitis B vaccine recommendations are:
- All adults 19–59 years and adults ≥60 years with risk factors should receive hepatitis B vaccines
- Adults ≥60 years without known risk factors may receive hepatitis B vaccines
Risk-based screening of hepatitis B among adults contributed to declines in hepatitis B cases overall; however, ten years ago, decreases in hepatitis B infections plateaued. Currently, rates are the highest among adults age 30–59 years old and have increased among adults age ≥40 years old.
The hepatitis B vaccine coverage among adults is suboptimal. Based on self-report data from the 2018 National Health Interview Survey, overall coverage was only 30% for adults age ≥19, and coverage across all adult age groups was suboptimal for those with identified risk factors. As age increases, rates steadily drop. Less than 20% of older adults with identified risk factors report being vaccinated. The youngest adult age groups may have been vaccinated under the universal child recommendation that took effect in 1991 or under the catch-up recommendations that took effect in 1999, therefore have better coverage. Universal recommendations for hepatitis B vaccine could increase the number of people who receive vaccines before the onset of morbidities such as obesity, diabetes, and chronic liver disease that might make the vaccine less effective.
Based on 2019 data, only 1/3 of people who reported acute hepatitis B reported risk factors based and the remaining 2/3 who reported acute infection denied any known risk factors or the risk factor data was missing. Risk factors include potential criminal or stigmatizing behavior, drug use, prison time, and/or multiple partners. The universal recommendation eliminates risk assessment before vaccination.
Racial and ethnic disparities existing among those who become infected with hepatitis B virus. In 2005, acute hepatitis B incidence among non-Hispanic black persons was approximately twice that of other racial and ethnic populations. In 2019, the rate of infection among non-Hispanic black adults was triple that of pacific islander adults who were twice that of Hispanic adults. Rates among children and adolescents of all ages and ethnicities had lower rates of infection since a universal hepatitis B vaccine strategy was implemented for children. Adult disparities could be reduced with universal recommendations.
A cost-effective modeling study compared the risk-based vaccine recommendation coverage with the three-dose or two-dose universal hepatitis B vaccination approach. Findings show that 23.7% of people were protected using the risk-based approach, compared to 44% in the universal three-dose series, and 45.7% in the universal two-dose series. Approximately 24% of chronic hepatis B infections and 23% of hepatitis B-related deaths were adverted with the universal hepatitis B vaccine approach compared to the risk-based approach. The two- and three-dose series were found to offer similar levels of protection against infection with the cost offset by the number of required doses.
The evidence supports a universal hepatitis B vaccination approach over a risk-based vaccination approach toward lowering barriers to vaccination as well as reducing hepatitis B infections. Universal hepatitis B vaccination recommendation for adults will provide the best chance of achieving hepatitis B virus goals. More vaccine tools are available than when the risk-based policy was first recommended:
- Two 3-dose monovalent vaccines are available that is safe and effective with long-term immunogenicity (>35 y)
- One 2-dose vaccine is available that is safe and effective
- One 3-dose, 3-antigen vaccine was recently FDA approved and ACIP recommended
Overview of Draft CDC Recommendations for Hepatitis B Screening and Testing
Screening and testing guidelines were presented as part of the FRN call last week and are posted in the Federal Register for public comment. The proposed recommendation is for screening and testing to be performed at least once in a lifetime for adults age ≥18. There are also plans to expand upon the current risk-based recommendation. Public comment closes June 3.
- Currently, the CDC is working on the first phase of promotion of the ACIP adult hepatitis B vaccination recommendations which have been published in the MMWR. Awareness is being increased via webinars.
- In the spring of 2022, there will be a review and response to the FRN comments.
- In the summer of 2022, revised testing guidelines will be submitted to CDC clearance.
- By the end of 2022, new guidelines will be published in MMWR and integrated hepatitis B testing and vaccination guidance.
Provider Outreach – Resources for Clinicians
- CDC’s Current Issues in Immunization April 20 Webinar
- Immunization Update on ACIP Recommendations for Hepatitis B, Pneumococcal and Zoster Vaccines; Mark Weng, MD, from CDC’s Viral Hepatitis program participated in this presentation.
- University of Washington – Hepatitis B Online
- Free continuing medical education, tools, and resources for clinicians, pharmacists, and others about hepatitis B, including vaccination
- Univ of Washington Hepatitis B online can be found at hepatitisB.uw.edu
- Immunize.org Resources
- Immunize.org updated its popular, Ask the Experts: Hepatitis B webpage, which includes an extensive list of clinical questions and answers incorporating the updated hepatitis B vaccination recommendation.
- Standing Orders For Administering Hepatitis B Vaccine to Adults
Ways to Promote Hepatitis Awareness Month in May 2022:
- Use and share CDC’s Hepatitis Awareness Month toolkit
- Engage with CDC on Twitter @cdchep
- Use the Awareness Month hashtags: #HepatitisAwarenessMonth #Hepatitis #HepAware2022
Implementation: ACIP Adult Hepatitis B Vaccination Recommendations and CDC Recommendations for Hepatitis B Screening and Testing
- Explore model hepatitis B programs to screen, vaccinate or link-to-care following the new universal screening and vaccination recommendations and associated clinical considerations
- Leverage Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments (IVHSP) with the second component being Core Viral Hepatitis Prevention Activities
- Utilize CDC partnerships and cooperative agreements for public and provider education
- Engage with federal and non-federal partners to explore implementation opportunities
- Improve immunization practices through collaboration, syndemic approaches, and innovation
Implementation Plan for Hepatitis B (HHS) – Jessica Deerin (OIDP)
Jessica Deerin, PhD, MPH, Viral Hepatitis Policy Advisor, Office of Infectious Disease and HIV/AIDS Policy (OIDP), gave a presentation on the Implementation Plan for Hepatitis B from HHS. VIEW PRESENTATION SLIDES.
The HHS Office of Infectious Disease and HIV/AIDS (OIDP) coordinated development of the Viral Hepatitis National Strategic Plan 2021–2025: A Roadmap to Elimination, which was released in January of 2021. This roadmap is for all stakeholders to work collectively to reach viral hepatitis elimination by 2030. This is the first strategic plan released that is considered an elimination plan. The updated universal hepatitis B recommendations are an important step toward this goal, as the progress on reducing the rates of acute hepatitis B have stalled.
The key highlights of the plan include:
- Elimination of viral hepatitis by 2030
- Improvement of viral hepatitis surveillance
- Active participation by all clinicians
- No wrong door approach – meeting people where they are by providing services wherever they catch the healthcare system in the community and providing the hepatitis B vaccine in a variety of settings
- Syndemic approach – holistic care, addressing co-occurring conditions such as HIV, STI, and substance use disorder programs, and social determinants of health
- Advancing research on hepatitis B cures and hepatitis C vaccine
- Focusing on disproportionally impacted populations and eliminating inequities and stigma associated with the vaccine recommendation
- Increasing vaccination among adults
The plan’s first goal is to prevent new viral hepatitis infection by increasing uptake of hepatitis B vaccination. To do this, it is important to address missed opportunities to expand the delivery of hepatitis B vaccination in high-impact settings and incorporate vaccination in primary care settings. Secondly, the financial and system barriers need to be reduced to be able to provide and receive viral hepatitis B vaccinations. This can be done by training providers on strategies to address vaccine hesitancy, by improving surveillance infrastructure to better monitor adult immunizations, and by researching and scaling up best practices in vaccination provision.
May is Hepatitis Awareness Month. During this month there will be a webinar on May 23 from 2:00–3:30 p.m. (ET) titled Federal Implementation of the Updated Adult Hepatitis B Vaccination Recommendations. We encourage all to incorporate hepatitis B vaccination messaging campaigns in your advocacy work.
Susan Farrell (HHS) on the National Standards for Adult Immunization Practice
There are four steps that all clinicians should follow at every clinical encounter with every adult patient:
- Assess the patient to determine which vaccines are right for them
- Identify the vaccines that the patient needs and clearly recommend those vaccines
- Offer needed vaccines or refer patients to another provider for the vaccinations
- Document vaccinations given and measure vaccination rates of providers’ patient panels
Implementation Plan for Hepatitis B (Hepatitis B Foundation) – Michaela Jackson (Hepatitis B Foundation)
Michaela Jackson, MPH, MS, Prevention Policy Manger, Hepatitis B Foundation, gave a presentation on the Implementation Plan for Hepatitis B from Hepatitis B Foundation. VIEW PRESENTATION SLIDES.
What does the new universal hepatitis recommendation mean for the communities?
- Increased access to hepatitis B vaccines
- Elimination of financial and systemic barriers to vaccination such as cost-sharing
- More providers will offer the vaccine and it will be easier to get vaccinated
- Health disparities and new hepatitis B infections will be reduced
- Health insurance coverage for the vaccine will improve
- Working toward a national goal of eliminating viral hepatitis by 2030
There are many opportunities to educate the community, but also many challenges. The challenges include:
- Low awareness among providers and patients
- Current adult hepatitis B programs are based on previous risk-based recommendations and not the new universal recommendations
- Funding comes from federal and not necessarily from the state; there are not as many funds to put toward adult vaccinations
- Adult immunization information infrastructure is lacking in the U.S.; therefore many adults do not know if they have been vaccinated/with which vaccine
- COVID-19 had been the focus and now the focus needs to shift to all vaccinations
Opportunities to take advantage of in educating the community include:
- The COVID-19 infrastructure needs to be capitalized on and utilized to expand to all adult vaccinations
- We have better capability to share information through virtual platforms to offer materials to share and utilize
- There are many opportunities to collaborate with key stakeholders such as pharmacies and pharmacists who have been at the forefront of immunizations during the pandemic.
- New implementation pathways have been paved by pandemic models and offer information on how to move forward with implementation
What the community needs you to know
Stigma and discrimination are persistent in communities that have been impacted by hepatitis B. With the new universal recommendations, there is potential to increase the rates among high-risk groups that will no longer need to have hard conversations with providers.
Providers can highlight that this now routine vaccination is for all adults and has nothing to do with risk. They may also highlight the link between hepatitis B and liver cancer, which is often not talked about due to stigma associated with the disease.
Be on the lookout for universal hepatitis B screening updates. Providers may not be aware of the new recommendations and it’s important to get the word out and share information. Patients also need to know that they now have the opportunity to get vaccinated.
Commentary by Donovan Robinson (PPHF Initiative)
As part of the Prevention Public Health Funding (PPHF) Initiative, Chicago began administering 16,000 does of hepatitis B vaccine via mobile unit in 2012 in 20 at-risk sites: DOC, drug treatment centers, HIV/STI, MSM healthcare, Asian CBOs, and homeless shelters. After 3.5 years after the funding ended, there are still 12 sites. Due to COVID-19 the mobile sites have moved inside the facilities, and we are not only administering hepatitis B vaccines, but also COVID-19, flu, pneumonia, tetanus, hepatitis A and B, and meningitis. Once you get these facilities on board, it is important to keep them because there will always be some type of outbreak or another disease such as meningitis, pertussis, flu, hepatitis A, etc. If you have somewhere already on board it is a lot easier to go in and administer these other vaccines and educate the community rather then trying to set up new partnerships during emergencies.
What do you think we could as a public health community leverage from the COVID-19 vaccine response that could help implement this new recommendation?
Trying to leverage the infrastructure that’s been set up with pharmacies could be helpful. There are some challenges there but that’s something that we are planning on exploring.
With COVID-19, the immunization systems were utilized more, and we have better access now to IIS for the hepatitis B vaccine. It’s important to make sure we are checking the vaccine registries before vaccinating and documenting those vaccinations.
Larger conversations are being had and now people are starting to realize that they need a lot more vaccines. We could include pamphlets when adults go for COVID-19 vaccines with information about hepatitis B, which is something that is easy and can go a long way.
Mobile units that have been deployed for COVID could be utilized for other adult vaccinations.
We now have a lot more people interested in vaccinations. What are your thoughts about making it leveraged so those new groups can be a part of the immunization advocacy community?
Any time someone goes in to get vaccinated for any vaccine is an opportunity to talk about other vaccines they might need. When I was getting my COVID-19 vaccine I had to wait fifteen minutes before I could leave; that’s a good opportunity to educate about other adult vaccines. A lot of new vaccine hesitancy has come from the COVID-19 vaccine and a lot of lessons we have learned from that can be applied here, as well. We are already seeing reports of increasing hesitancy about the hepatitis B vaccine coming out with the new recommendation. We need to prepare for that.
There is an advantage with hepatitis B vaccines because they have been available since 1982, and have an excellent safety profile, so that’s something that can be emphasized. We can also talk about the positives that these vaccines bring and linking it to childhood disease that’s been prevented. We can also prevent adult diseases if we broaden our emphasis and leverage some of the same approaches used in the childhood program.
Nine out of ten times if you start with the vaccine is safe and effective and drill that into people’s heads, that does a lot of the work for you in the conversation.
What are the good ways for immunization-focused organizations to connect with hepatitis B advocates in the community?
We are a small community, but we try to be available for anyone who wants to be a part of the hepatitis B community. Hep B United is a coalition across the U.S. that have partners that do a lot of on-the-ground work. They have a wide reach. If you want to connect with any of the Hep B United groups, please contact us so we can help you get connected. Contact information can be found at: http://www.hepbunited.org/contact-us.
The funding that has gone into adult immunizations at the state and local level has been increasing since COVID-19. Will this continue?
We are working closely with colleagues at NCIRD to try to identify opportunities. We are very anxious to try to leverage the COVID-19 infrastructure funding toward improving adult vaccination for hepatitis B.
It’s important for state and local health departments to have coverage data that is state-specific to help them guide their intervention. Are there any plans to be able to provide states with state-specific coverage data?
We are working closely with NCIRD and going to look at tracking of the new recommendations. We are also being cognizant of the different vaccines that are available and how to best measure series completions as well as uptake. These are ongoing conversations.
The immunization registry is very important. A lot of these people are transient so they are not going to keep their immunization cards. We tell them every time they come to see us or a pharmacy that we/they will look at the historical vaccination record. That way we aren’t wasting doses and can give them an additional printout if needed.
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