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 hepatitis A and B, 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.1

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.2

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.3 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 HCPLive, 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.

References

1. World Health Organization. Hepatitis B. April 9, 2024. Accessed March 28, 2025. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b

2. Word Health Organization. Hepatitis A. February 12, 2025. Accessed March 28, 2025. https://www.who.int/news-room/fact-sheets/detail/hepatitis-a

3. National Foundation for Infectious Diseases. Vaccines and Liver Disease. October 2024. Accessed March 28, 2025. https://www.nfid.org/immunization/vaccines-and-liver-disease/