ACIP recommends hepatitis B vaccine for diabetics, HPV vaccine for men

Two new recommendations from the Advisory Committee on Immunization Practices (ACIP) outline hepatitis B vaccination for diabetic adults and human papillomavirus vaccination in males ages 9 to 26.

Both recommendations appeared in the Dec. 23, 2011 Morbidity and Mortality Weekly Report.

Hepatitis B vaccination should be administered to all diabetics ages 19 through 59 (evidence type 2, randomized controlled trials with important limitations, or exceptionally strong evidence from observational studies).

Vaccination should be completed as soon as possible after a diabetes diagnosis, but no vaccine, dose or schedule conferred an advantage over another in the evidence. Hepatitis B vaccine may be given during visits scheduled for other reasons as long as minimum intervals between doses are observed. There is no maximum interval between doses that makes the hepatitis B vaccination series ineffective, the ACIP said. No serologic testing or additional hepatitis B vaccination is recommended for adult diabetics who have already received a complete vaccination series.

The hepatitis B vaccination series can be given safely at any age, but current hepatitis B vaccines are less efficacious and less cost-effective among older adults, the experts said. Thus they recommended that hepatitis B vaccination may be given at a clinician's discretion in diabetics older than age 60 (evidence type 2). Clinicians should consider the patient's likelihood of acquiring hepatitis B (including the risk posed by an increased need for assisted blood glucose monitoring in long-term care facilities), the likelihood of experiencing chronic sequelae if infected, and the declining immunologic responses to vaccines that are associated with frailty.

According to economic models, the incremental cost per quality-adjusted life-year (QALY) saved from vaccinating adults with diabetes was $75,100 for those ages 20 through 59 but increased substantially after age 60.

HPV4 was licensed in 2009 for use in males to prevent genital warts. The FDA added prevention of anal cancer in males and females as an indication for use in December 2010. For HPV vaccination in men, the ACIP recommends routine vaccination of males ages 11 or 12 years with HPV4 administered as a three-dose series (evidence type 2). Vaccination with HPV4 is also recommended for males ages 13 through 21 who have not already been vaccinated or who have not received all three doses in the series. Vaccination may be administered in men ages 22 through 26 years. Recommendations for administration and precautions have not changed from previous recommendations.

At the current vaccine price, adding male vaccination at age 12 years to a female-only vaccination strategy would cost approximately $20,000 to $40,000 per QALY in more favorable models and approximately $75,000 to more than $250,000 per QALY in less favorable models. Vaccination of adult males becomes less cost-effective as age at vaccination increases, and models suggest the cost per QALY gained by vaccinating males older than 21 years would be about two to four times that of vaccinating teenage males.