Immune Response of Hepatitis B Vaccine Among PersonsWith Diabetes A systematic review of the literature

In October 2011, the Advisory Committee on Immunization Practices (ACIP) recommended hepatitis B vaccination for adults with diabetes in the United States (1). Serosurvey data from the 1999–2010 National Health and Nutrition Examination Survey found that noninstitutionalized adults aged $18 years with diabetes have an increased seroprevalence of past or current hepatitis B virus (HBV) infection (1). Outbreaks of hepatitis B in elderly persons with diabetes in long-term care facilities have been linked to diabetes care procedures (including blood glucose monitoring), with likely vehicles for transmission including spring-loaded finger-stick devices used on multiple patients and blood glucose testing meters that were not cleaned between uses on different patients. In the U.S., hepatitis B vaccination is routinely recommended for infants, children, and adolescents. It also is recommended for adults at increased risk of HBV infection, including persons with end-stage renal disease or chronic liver disease, health care personnel, injectiondrug users, and men who have sex with men (2–4). A hepatitis B vaccination series results in protection in a high proportion (.95%) of infants, children, and young adults (5). As with other vaccines, the efficacy of the hepatitis B vaccine progressively declines with advancing age, as well as with the presence of obesity and other comorbid conditions (6–12). Results of studies of the hepatitis B vaccine among persons with diabetes generally follow these patterns (13,14). Primary hepatitis B vaccination usually consists of 3 (or 4) doses of 10 or 20 mg of recombinant hepatitis B surface antigen (HBsAg) protein administered intramuscularly into the deltoid muscle on a 0-, 1-, and 6-month schedule (Table 1). Alternative schedules are U.S.approved for routine vaccination for specific ages and vaccine formulations, and they elicit dose-specific and final rates of seroprotection similar to those obtained on a 0-, 1-, and 6-month schedule (4). Two single-antigen recombinant vaccines, Recombivax HB (Merck & Co, Inc., Whitehouse Station, NJ) and Engerix-B (GlaxoSmithKline Biologicals, Rixensart, Belgium), and one combination hepatitis A/hepatitis B vaccine, Twinrix (GlaxoSmithKline Biologicals), are approved for use in adults in the U.S. (15). Hepatitis B vaccines are safe for all age groups. Administration of additional vaccine doses for nonresponders is not associated with an increase in adverse events (16). Vaccination is not contraindicated in persons with autoimmune or chronic diseases, or in those who are pregnant (4). No review has been published of the efficacy of the hepatitis B vaccine among persons with diabetes; results of studies among persons with diabetes show some heterogeneity comparedwith adultswithout diabetes. Differences in diabetes type, management, and glycemic control, as well as vaccine, dosage, administration route, or schedule, may underlie this heterogeneity. The 2011 ACIP recommendation for hepatitis B vaccination for adultswithdiabetes, an increasing incidence of diabetes, and the high prevalence of diabetes among certain groups recommended for hepatitis B vaccination (e.g., persons with end-stage renal disease) suggests that a review of vaccine efficacy among persons with diabetes may be timely.We therefore performed a systematic review of the literature and summarized the evidence for seroprotection after hepatitis B vaccination among persons with diabetes.