Diabetes and Obesity Journal Club Carina Signori Endocrinology Fellow

 Causes acute and chronic infection of the liver.  Leads to substantial morbidity and mortality.  Since 1996, 29 outbreaks of HBV were reported in long-term care facilities (LTC) in the U.S.  25 of the 29 were adults with diabetes receiving assisted blood glucose monitoring.  Therdfore, ACIP (Advisory Committee on Immunization Practices) evaluated risk for HBV in diabetic adults.  Based on their finding, they revised the recommendations for HBV vaccination.

 Discuss HBV  Risk  Morbidity/mortality  Infection control  Vaccine  Cost-effectiveness  Discuss new ACIP HBV recommendations for DM

 Population risk for HBV infection in adults with DM compared to nondiabetics – (estimated from confirmed cases )  Aged yo DM  2.1 x (95% CI= ).  Aged ≥ 60 yo DM  1.5x (CI ).  Annual incidence of reported cases in DM:  1.8 per 100,000 (CI= ).  NHANES data from :  60% (p<0.001) higher HBV antibody (HB core Ag) among persons ≥18yo with DM compared to those without diabetes.  Prevalence ratios:  1.7 (CI= ) aged yo.  1.3 (CI= ) aged ≥60yo.

 National surveillance data: 3371 acute HBV reported in 2009  47% of 2126 infections which info was available for were hospitalized.  1% of 1900 infections that info was available were fatal.  In other analysis, high case-fatality rate among acute HBV-infected diabetes compared to those without diabetes.  Chronic HBV infection is associated with higher M and M  Leads to cirrhosis and cancer in ≥15% of affected adults.  Chronic HBV is a reservoir for continuing HBV transmission.  Diabetics have 2x risk for chronic NAFLD and HCC than those w/o DM.

 HBV is highly infectious and enviromentally stable.  Can be transmitted by medical equipment that is contaminated with blood not visible to eye.  Percutaneous exposure to HBV results from assisted monitoring of blood glucose in diabetics.  Transmission occurred from multipatient use of finger stick devices designed for single patient use and inadequate disinfection and cleaning of blood glucose monitors between patients.  Infection control guidelines targeting safe blood glucose monitoring for LTC settings were published in 2005.

 In the U.S.  2 single antigen recombinant hep B vaccines Recombivax HB (Merck) Engerix-B (GSK)  1 combination hep A and hep B vaccines: Twinrix (GSK)  Vaccine consists of 3 doses of vaccine administered IM at 0, 1, and 6 months  Seroprotection from vaccine:  Decreases with age, obesity, smoking, immunosuppresion and comorbid conditions (including diabetes).  Revaccination with 1-3 additional doses safely increases proportion of adults who achieve a protective level of anti-HBs (≥10 mIU/mL)

 The Hepatitis Vaccines Work Group developed economic models that yielded age-stratified calculations of incremental cost per quality- adjusted life year (QALY) saved based on vaccinating adults with diabetes again HBV.  Estimated cost per QALY saved= $75,1000 (persons aged 20-50yo) Cost Increased with age.  1 time vaccination covering 10% of unvaccinated U.S. adults with DM age yo (~529,047 people) would prevent 4271 HBV infections, 467 hospitalizations, 256 chronic cases, 33 HCC, 13 liver transplants, 130 deaths.  Postvaccination serologic testing and revaccination would add considerable cost with limited increase in disease protection.

 Hep B vaccination should be administered to unvaccinated adults with diabetes mellitus aged yo (recommendations category A).  Hep B vaccination may be administered at the discretion of the treating clinician to unvaccinated adults with DM aged ≥60 yo (recommendation category B).

 Shared use of blood-contaminated equipment increases risk of HBV.  Continued efforts are needed to increase adherence to good infection control practice.  HBV vaccine should be given as soon as diabetes is diagnosed.  There is no particular vaccine that is recommended.  No serologic testing or additional HBV vaccination is recommended for adults who complete a series of hep B vaccine.

 HBV vaccine can be given safely at any age but less efficacious and less cost-effective for older adults.  Decisions to vaccinate adults with DM ≥60yo should consider the likelihood of acquiring HBV.  Vaccine may be administered during health care visits scheduled for other purposes.  As long as minimum intervals between doses are observed.  There is no maximum interval between doses that makes the vaccine series ineffective.