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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, and also voted to recommend expanded use of vaccines against Ebola and orthopoxviruses, and approved the 2022 adult and childhood immunization schedules.

HBV Vaccine

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.

Ebola, Orthopoxvirus Vaccines

Pre-exposure vaccination with rVSVΔG-ZEBOV-GP (Ervebo) was recommended for healthcare personnel (HCPs) caring for or transporting Ebola patients at special pathogens treatment centers, and laboratory workers and support staff at Laboratory Response Network facilities that may handle replication-competent Ebola virus specimens.

The votes were both 11-4, with the dissenters wanting a less stringent recommendation -- "shared clinical decision-making" -- rather than a full-out recommendation, given the reactogenicity associated with the vaccine.

Wilbur Chen, MD, of the University of Maryland, who voted yes, pointed out that these are "occupational medicine vaccines," and designed to be part of "workforce management for the facility."

Dissenting committee members felt that the workers themselves should be able to balance the benefit/risk and inquired about the "threat level" to these workers.

"I feel strongly that people should have a choice," said Kathy Poehling, MD, of the Wake Forest School of Medicine in Winston-Salem, North Carolina, who voted no.

ACIP, however, was united in their 15-0 recommendation for Jynneos, a vaccine against orthopoxviruses, including smallpox and monkeypox. CDC staff noted that unlike the current vaccine (ACAM2000), Jynneos vaccine virus is replication-deficient, with no "take" after vaccination.

The committee voted unanimously for the following recommendations for Jynneos:

• An alternative to ACAM2000 for research and clinical laboratory personnel performing diagnostic testing, and for designated response team members at risk for occupational exposure to orthopoxviruses
• An alternative to ACAM2000 for HCPs administering ACAM2000 or caring with patients with replication-competent orthopoxviruses, under shared clinical decision-making
• Every 2 years as a booster for people at continued risk of exposure to more virulent orthopoxviruses
• Every 10 years as a booster for people at continued risk of exposure to replication-competent, but less virulent orthopoxviruses
• As a booster for people at continued risk of exposure, who received an ACAM2000 primary series

The committee also voted 15-0 to approve the 2022 adult and child immunization schedules, including dengue vaccination for children ages 9-16 years living in endemic areas.

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

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