Adults ages 59 and younger, and adults ages 60 and up who have risk factors for hepatitis B virus (HBV), are recommended to be vaccinated against HBV, the CDC Advisory Committee on Immunization Practices (ACIP) said in a unanimous vote Wednesday.

ACIP voted 15-0 to recommend this split philosophy for HBV vaccination. The initial recommendation from CDC staff was universal HBV vaccination for all adults ages 18 and up, but an amendment to separate out the age groups, and retain the risk-based recommendation for older age groups, passed 8-7 earlier in the day.

The current risk-based recommendation applies to:

• People at risk for infection by sexual exposure or percutaneous or mucosal exposure, such as injection-drug users
• Other risk groups, such as international travelers with high or intermediate levels of endemic HBV infection
• People with chronic liver disease
• Incarcerated people
• People living with HIV

This would be consistent with the current immunization schedule, with CDC staff adding that any adult who wishes to receive protection may receive the vaccine, meaning all adults ages 60 and up who do not have any HBV risk factors.

At issue was mainly cost parameters. CDC staff presented a slide that showed the cost-effectiveness analysis with an age limit of 59 versus all adults. The total incremental cost was $10 billion less for adults ages 59 and younger versus all adults (around $22 billion vs $32 billion), and the doses given rose from 298 million to 352 million.

Interestingly, a recommendation for universal vaccination was only estimated to reduce acute HBV infections by 24% compared to a 23% reduction for an age limit of 59 or younger.

ACIP chair Grace Lee, MD, also pointed out that while the cost analysis examined a vaccination program, it did not include the full scale of the intervention, which included a screening program for HBV seropositivity.

She speculated the cost was “probably a conservative estimate” and pointed out that there was little gain for increased cost.

“The cost is high for people over 60,” added Beth Bell, MD, of the University of Washington in Seattle.

The other side of the argument — and one supported by the majority of liaison members who spoke up — was for universal vaccination, with committee members arguing that it would help to promote health equity, especially given the racial/ethnic disparity among HBV cases, with more adults affected in minority communities.

“A simplification of this recommendation will reach more individuals at risk … and promote health equity,” especially among those disproportionately affected by HBV, said Sybil Cineas, MD, of the Warren Alpert Medical School of Brown University in Providence, Rhode Island.

Liaison members agreed. Former ACIP chair Carol Baker, MD, spoke on behalf of the Infectious Diseases Society of America (IDSA) and said the organization “strongly supports universal hepatitis B vaccination.”

“Risk-based [recommendation] is a failed policy. The evidence is overwhelming,” she added.

Jason Goldman, MD, of the American College of Physicians, noted that any risk-based recommendation would mean patients would have to disclose their risk factors to their providers, which many may not be comfortable doing.

As always, all ACIP recommendations are not considered final until they are published in the Morbidity and Mortality Weekly Report.