DDW 2011: Despite High Risks, Vaccination Rates Are Low in Chronic Liver Disease Patients with Diabetes

Low vaccination rates among patients with CLD and diabetes have grave public health implications.

Low vaccination rates among patients with chronic liver disease (CLD) and diabetes mellitus (DM) have grave public health implications and justify better implementation of current vaccination recommendations, according to experts at a Digestive Disease Week 2011 annual meeting poster and press conference. Beyond the fact that professional societies recommend vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) among CLD patients, said Zobair M. Younossi, MD, vice president of Inova Health System, Falls Church, VA, recent data suggest that DM patients are at higher hepatitis B virus risk and should be considered for vaccination, as well, because they have a very high rate of undiagnosed nonalcoholic fatty liver disease.

Introducing Younossi’s presentation at the press conference, Adrian Di Bisceglie, MD, chief of hepatology at Saint Louis University School of Medicine, pointed out that liver-related disease (cirrhosis, hepatocellular carcinoma, and liver failure) is the number ten cause of death in the US and leads to about six thousand liver transplants yearly. Associated costs are enormous. “To the extent that we can prevent some of these events, was can minimize or lower costs,” Di Biscelglie said.

When patients who have pre-existing CLD become infected acutely with HAV or HBV, Younossi stated, they can develop severe forms of liver disease leading to organ failure or even death. Individuals with type 2 diabetes have very high rates of non-diagnosed nonalcoholic diabetic liver disease, a form of CLD that can lead to cirrhosis. In order to assess the efficacy of implementation of recommendations for vaccination, Younossi and colleagues reviewed several cycles of the National Health and Nutrition Examination Survey (NHANES) conducted between 1999-2004 and 2005-2008 to assess HAV and hepatitis B virus (HBV) vaccination rates in US patients with CLD and DM. In separate comparisons, those without CLD or those without DM were considered to be controls. The two cohorts included 22,466 adults (13,502 and 8,964, respectively). Among these, 3,239 had CLD (12.0% HCV, 68.7% non-alcoholic fatty liver disease (NAFLD), and 19.3% had other liver disease) and 2,480 had DM.

Analysis showed that during the most recent NHANES cycle, 20.0±1.5% and 32.0± of CLD patients reported having HAV and HBV vaccinations, respectively. On the other hand, Younossi said, only 15.6± 1.8% and 21.8±1.8% of patients with DM reported HAV and HBV vaccinations. Respective rates in controls were 20.9±1.0% for HAV and 35.2

“What we found was that less than a third of patients with CLD are currently vaccinated. The numbers, in fact, are very similar to that of the general population. So despite the risk for very severe forms of liver disease, they are not vaccinated at the high level you would expect,” Younossi said. The further finding noted by Younossi was while there has been an increase over time in vaccination rates among CLD patients, the increase is the same as that in the general population. In the DM population, however, vaccination rates against HAV and HBV are even lower. “That’s particularly important in the light of reports of HBV transmission in DM patients leading to severe liver disease,” Younossi said.

In multivariate analysis, independent predictors for both HAV and HBV vaccinations for the entire study cohort included age<60, non-Caucasian race and lower alcohol intake. In a separate multivariate analysis, the same predictors were also observed for the CLD cohort. In the DM cohort, only age<60 was independently associated with both HBV and HAV vaccination.

Younossi concluded, “Given the public health implication of acute HAV and HVB in CLD patients, better implementation of the current vaccination recommendations needs to be considered.”