Doctors are told to use hepatitis B vaccine sparingly because of global shortageBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3801 (Published 08 August 2017) Cite this as: BMJ 2017;358:j3801
All rapid responses
Current shortages of the monovalent hepatitis B virus (HBV) vaccination have made recent headlines in the national UK media, including representation in the BMJ by Zosia Kmietowicz (1). HBV deserves to make headlines; an estimated 250 million individuals are chronically infected (10-fold more than HIV), and there has been chronic neglect of funding, political advocacy, research and clinical services. New aspirations are reflected by United Nations Sustainable Development Goals, with a suggested aim of ‘elimination of [viral hepatitis] as a public health threat by 2030’ (2). Moving towards this ambitious target will rely on sustained, unified, international efforts that pursue parallel efforts in active diagnosis, provision of treatment, and a variety of preventive strategies. Vaccination is a cornerstone of prophylaxis, and we cannot afford to be complacent on this front.
Broadly, HBV vaccination can be thought of in two categories. First, it is provided to infants as part of the World Health Organisation Expanded Programme on Immunisation (EPI), commonly in pentavalent or hexavalent combinations with other routine childhood vaccinations (3); these vaccines are currently not subject to shortage. The second approach is a monovalent HBV vaccine manufactured for the UK market by GlaxoSmithKline (GSK; https://www.gsk.com/). This is provided to individuals deemed to be at risk of HBV infection, such as household contacts of individuals with HBV infection, travellers to endemic areas, MSM, injecting drug users, sex workers and healthcare workers (4). This vaccine is also used for post-exposure prophylaxis, which includes babies born to HBV-infected mothers, recipients of needle-stick injuries, and cases of high risk sexual contact. GSK has currently assured supplies of the infant formulation, but adult preparations are subject to shortage, as described by Kmietowicz (1); (https://www.gsk.co.uk/supply.html).
Public Health England has provided national guidelines to unify an approach to vaccination, advocating careful case-by-case risk assessment, emphasising the need to avoid stock-piling, ensuring prioritisation for high-risk neonates, and reinforcing key educational messages (5). In a low endemicity setting, such as the UK, we can benefit from this measured, expert response; there is no public health crisis, and a triaged approach means that individuals at high risk should continue to be protected. Enhanced awareness and education, and recent media attention, are appropriate and desirable consequences.
There is a risk of complacency in the UK as a result of the declining incidence of new acute infections (6), and a low population prevalence (<2%). However, we should not take our eye off the ball. It should be difficult to justify shortages of a robust, safe vaccine that has been successfully manufactured for over two decades. A proportionate public, professional and political response must account for the vulnerable nature of the highest risk groups, who themselves may be without political voice. The reality is that, in the absence of a cure, every new individual case of HBV infection should be regarded as an inexcusable, preventable failure.
Acquiring, maintaining and preserving vaccine supply should be a priority and is a duty of care that rests on policy-makers, funders, pharma and healthcare providers. Neglect on all of these fronts is a potential contributor to current shortages. GSK should share more details of the factors underpinning current supply issues; minimising the impact of the current situation, and avoiding future shortages, will rely on a careful assessment of the supply chain from its roots in political will and sustainable funding, through production and distribution, to the end point of clinical use. If future interruptions to vaccine stocks are a realistic concern, we should expand our horizons to investing in improved manufacturing processes and/or engagement with alternative suppliers.
This situation needs to be closely monitored, and we must listen to feedback from those who administer HBV immunisations. Is it realistic to assess and prioritise one person’s need over those of another? Can we rely on education to change high risk behaviour in the short term? Are vaccines reliably and promptly accessible for those who need them? Let us use this current interruption in supply to scrutinise practice, to build advocacy, to re-educate ourselves, our patients and the public about this important yet neglected infection, and to ensure we get vaccine supply back on track.
Philippa Matthews is funded by the Wellcome Trust
1. Kmietowicz Z. 2017. Doctors are told to use hepatitis B vaccine sparingly because of global shortage. BMJ 358:j3801.
2. Griggs D, et al. 2013. Policy: Sustainable development goals for people and planet. Nature 495:305-307.
3. Torjesen I. 2017. UK adds hepatitis B to infant vaccination schedule. BMJ 358:j3357.
4. Immunisation Against Infectious Disease: The Green Book. The Stationery Office under licence from the Department of Health. 2013.
5. Public Health England. Hepatitis B vaccination in adults and children: temporary recommendations from 4 August 2017. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
6. Public Health England. Acute hepatitis B (England): annual report for 2015. Health Protection Report 2016; weekly report 10(28). https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
Competing interests: No competing interests
Risk of Aquiring Diseases will increase in Vaccines Shortage period.
Own manufacture of vaccines like hepatitis B Vaccines in all countries are lmportant. We shouldn't relay upon one or a few companies for the production of vaccines and life saving drugs to face the short supply at any time and anywhere in the world.
Competing interests: No competing interests