Need for Shifting Responsibility for Adult Hepatitis B Vaccination from the Patient to the Healthcare Provider

A comprehensive review article titled, ‘Need and Rationale of the Adult Immunisation in India: A Review’,[1] has been published in this journal. However, in our considered opinion, this article is missing a highly relevant aspect regarding hepatitis B (Hep B) adult vaccination. According to the World Health Organization’s Global Hepatitis Report 2024, India accounted for 11.6% of the global viral hepatitis disease burden in 2022, with 254 million people living with Hep B, making it the country with the second-highest disease load after China (27.5%).[2] It is evident that Hep B vaccine has been in use since the 1990s globally. In India, it was introduced in the Universal Immunization Program starting 2007–2008 with nationwide roll-out by 2012.[3] Hep B vaccination in children has effectively prevented virus spread, significantly reducing Hep B infection rates among routinely vaccinated infants and children. The demographic shift in low- and middle-income countries, such as India, has resulted in a growing adult population, underscoring the necessity of vaccinations to achieve universal healthcare.[4] Centres for Disease Control and Prevention recommends extending this vaccine protection to all adults through a catch-up vaccination program.[5] Advisory Committee on Immunisation Practices suggests that individuals aged 19–59 and those aged 60 or older with risk factors for Hep B should get the Hep B vaccine. At the same time, those without known risk factors in the same age range may also receive it. Previous vaccine recommendations encouraged providers to administer the Hep B vaccine to all patients who requested it. The new language for the 60-plus age group aims to prompt providers to offer the Hep B vaccination to patients in that group instead of waiting for them to request it, shifting the responsibility of considering vaccination from the patient to the provider.[6] Individuals who have ever received a Hep B vaccine series or have a past case of hepatitis B virus (HBV) infection should not get another Hep B vaccine, although there is no proof that more shots would harm them. Nevertheless, in certain situations, such as when an infant is born to someone who tests positive for hepatitis B surface antigen (HBsAg), a healthcare provider or a person on dialysis, revaccination might be necessary, as suggested by the 2018 ACIP recommendation.[6] Cohen et al.[7] suggest that universal screening with the three-test panel (HBsAg, Hep B surface antibody and Hep B core antibody) will identify susceptible persons who will benefit from vaccination. ACIP advises that serological testing if conducted, should not impede the vaccination of individuals who are at risk. It is typically recommended to administer the first dose of the vaccine right after collecting the blood sample. Therefore, it would be best to conduct screening and immunisation during the same visit rather than waiting for the screening results to vaccinate a susceptible person.[8] The adult vaccination in general and Hep B vaccination rates in India are concerningly low.[9,10] Current estimates show that only 22.7% of adults have received all three doses of the HBV vaccine, 8.6% are inadequately vaccinated, 18.5% remain unvaccinated and 50.3% are unsure of their vaccination status.[10] One reason is that the disclosure of risk factors and screening requirements can discourage individuals from seeking vaccination due to specific barriers they face, such as stigma, low health literacy and logistical challenges such as cost and access to health care. To increase vaccination rates and reduce disease cases, prevention through universal vaccination is essential to a multipronged approach to disease elimination. Evidence from various countries shows that provider-driven vaccination strategies can be very effective. For example, Taiwan reduced its HBsAg rates from 19.7% to 0.6% in 1984 by implementing universal vaccination and maternal screening. In Egypt, a mandatory vaccination policy resulted in 82% coverage among healthcare workers, while Australia and New Zealand achieved 77% coverage through systematic vaccination programs. The low uptake of Hep B vaccination among adults can be attributed to several factors, including vaccine hesitancy, a lack of awareness regarding the importance of adult vaccination and the current approach where vaccination is largely patient initiated. Learning from these successful examples can help shift the responsibility for vaccination to healthcare providers.[11] The recent digital innovations such as U-WIN could effectively facilitate the scaling up of adult Hep B vaccination in India.[12] A recent publication from India[13] highlights the importance of primary health care in strengthening disease prevention and control in India, particularly for hepatitis. The paper advocates for decentralised, community-based approaches, including integrating hepatitis services into primary care, training health workers, conducting screening campaigns and linking primary care centres with specialised facilities. These strategies aim to enhance accessibility and affordability for rural and underserved populations, thus significantly contributing to hepatitis elimination in Southeast Asia. Key recommendations include universal screening, community education, integration with existing services such as HIV and TB and decentralised treatment delivery. The Punjab model demonstrates that such approaches can achieve high cure rates (93%) while improving service access. Financial support and sponsorship Nil. Conflicts of interest None declared.