Paul Kwo, MD, is a professor of medicine and director of hepatology at Stanford University.

Paul Kwo, MD

Addressing Barriers to Hepatitis Vaccination, with Paul Kwo, MD

Chronic liver disease affects millions of people worldwide, increasing susceptibility to severe complications from viral infections like 

, both of which can accelerate liver damage and lead to subsequent liver failure or hepatocellular carcinoma.

In 2022, an estimated 254 million people were living with chronic hepatitis B infection, with 1.2 million new infections each year. Hepatitis B resulted in an estimated 1.1 million deaths, primarily from cirrhosis and hepatocellular carcinoma.

Although hepatitis A infection is most common in low- and middle-income countries with poor sanitary conditions and hygienic practices, in the US, hepatitis A outbreaks have been reported among persons experiencing homelessness. Unlike hepatitis B, hepatitis A does not cause chronic liver disease, but it can cause mild to severe symptoms and rarely fulminant hepatitis.

Because people with chronic liver disease are at an increased risk of hepatitis infection and related complications, vaccination for both hepatitis A and B are recommended.

 However, several barriers exist that prevent eligible individuals from getting vaccinated, starting with healthcare providers ordering the appropriate serologic tests and identifying patients who need vaccination. From there, the vaccine series itself can also serve as a barrier.

“For hepatitis B, where you have to give 0, 1 and six months for the 3 dose [vaccine], it’s highly effective, and if that’s what you have, wonderful. I don’t want to say it doesn’t work, but it’s a barrier,” Paul Kwo, MD, a professor of medicine and director of hepatology at Stanford University, told 

, describing the superior effectiveness of a 2-dose vaccine.

Similarly, Kwo notes that hepatitis A vaccination requires 2 doses spaced 6-12 months apart. While he acknowledges that even a single dose offers some protection, he says encouraging completion of the full series remains a priority for optimizing patient protection.

Kwo also calls attention to the role healthcare providers—including primary care physicians, hepatologists, and gastroenterologists—play in actively identifying and vaccinating eligible patients. However, vaccine access varies. While some clinics stock vaccines, others do not, requiring referrals to public health departments, pharmacies, or other providers.

“I think one of the most exciting things on the horizon is the incorporation of the hepatitis B vaccination strategies to improve functional cure,” Kwo said, citing novel approaches like antisense oligonucleotide therapies and preliminary data on experimental therapeutic vaccines being developed to stimulate T-cell activity against hepatitis B virus. “Over time, as the design of these therapeutic vaccines, the adjuvants, and the antigens are refined, I think that this may also turn out to be part of a strategy to achieve functional cure.”

Editors’ note: Kwo has no relevant disclosures.

World Health Organization. Hepatitis B. April 9, 2024. Accessed March 28, 2025. 

https://www.who.int/news-room/fact-sheets/detail/hepatitis-b

Word Health Organization. Hepatitis A. February 12, 2025. Accessed March 28, 2025. 

https://www.who.int/news-room/fact-sheets/detail/hepatitis-a

National Foundation for Infectious Diseases. Vaccines and Liver Disease. October 2024. Accessed March 28, 2025. 

https://www.nfid.org/immunization/vaccines-and-liver-disease/

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Kwo describes different barriers to hepatitis A and B vaccination for people with liver disease and looks ahead to future innovations and novel strategies.

The Need for Hepatitis Vaccination in Chronic Liver Disease, with Paul Kwo, MD

“Vaccinations are a very important part of care in those who have chronic liver disease because for 2 of the hepatitis viruses that cause substantial morbidity and mortality… we have vaccines that can actually neutralize and prevent infection,” Paul Kwo, MD, a professor of medicine and director of hepatology at Stanford University, explained to 

He goes on to reference recommendations from the Advisory Committee on Immunization Practices supporting hepatitis B vaccination in infants, children ≤ 18 years of age, adults 19-59 years of age, and adults ≥ 60 years of age with risk factors for hepatitis B. Kwo additionally cites success seen with the introduction of a hepatitis B vaccine in Taiwan the 80’s, which led to reductions in hepatocellular carcinoma incidence.

“Worldwide, not just for hepatitis viruses or liver disease, but any infectious disease that has been eliminated, vaccination has been an important part of that strategy,” Kwo said. “So you think of mumps, rubella. You can see now that measles is coming back because people aren't getting vaccinated, but prior to that, vaccination was an effective strategy.”

Accordingly, he emphasizes the importance of hepatitis vaccination in everyone who is a candidate, especially those with chronic liver disease. For these patients, Kwo says it is important that clinicians screen for hepatitis B using a triple panel test—checking for surface antigen, surface antibody, and core antibody to determine which patients should be vaccinated and which patients need to be educated about the risk of reactivation.

Discussing vaccine options, Kwo notes that the 2-dose Heplisav hepatitis B vaccine has higher seroprotection rates than the traditional 3-dose series due to its immune-boosting mechanism. While the 3-dose vaccine is effective, he says completing the full series can be challenging, potentially contributing to its lack of robustness relative to the 2-dose vaccine.

Kwo also calls attention to increasing rates of hepatitis A due to factors like international travel, poor hygiene, and increased homelessness, underscoring the importance of vaccination among those with chronic liver disease in order to prevent outbreaks. In addition to several 2-dose vaccines, he highlights the utility of a combined hepatitis A and B vaccine, Twinrix, as well as salvage strategies to achieve seroprotection in nonresponders.

“We need to just go out there and find these individuals and make sure that we're appropriately vaccinating all of the large population with chronic liver disease and who are at risk for hepatitis B,” Kwo said.

World Health Organization. Hepatitis B. April 9, 2024. Accessed March 27, 2025. 

Word Health Organization. Hepatitis A. February 12, 2025. Accessed March 27, 2025. 

National Foundation for Infectious Diseases. Vaccines and Liver Disease. October 2024. Accessed March 27, 2025. 

Kwo explains why hepatitis A and B vaccination is important for people with liver disease and reviews different vaccine options.

Paul Kwo, MD

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