Audit of Outcome of Super-Accelerated Hepatitis B Vaccination Schedule in a Genitourinary Medicine Clinic

By Jones, O; Sankar, K N

Summary: An audit of outcomes from the first year of implementation of a super-accelerated hepatitis B vaccination schedule was performed. One hundred and sixteen patients commenced vaccination for hepatitis B in the study period. All notes were located and reviewed. In all, 72.4% of patients completed three vaccinations compared with 61.5% in an earlier period using the old schedule. Serological response for 39 patients was measured at approximately 12 weeks post commencement of vaccination. Of these 69.2% had mounted some serological response, 48.7% a good response. As expected, a faster vaccination schedule improves completion rates for the first three injections. Early serological responses are encouraging and comparable to published data for new schedule vaccination responses at 12 weeks.1 It is anticipated that serological response will continue to improve over the year before a booster dose of hepatitis vaccination is due.

Keywords: hepatitis B, vaccination, genitourinary medicine clinics

Introduction

A super-accelerated vaccination schedule for hepatitis B was introduced in this clinic in August 2002. Three doses of ENGERIX B vaccine (1 mL of 20 g) are given intramascularly into deltoid on days 0, 7 and 21. A further booster dose at one year should be advised, which can be obtained via the clinic or general practitioner (GP) if patient prefers. The vaccination is offered to patients who have not been previously vaccinated but are at continuing risk of acquiring infection. When vaccination occurs over several months, compliance can be a problem and super-accelerated vaccine courses were thought to improve compliance. However, there may be a reduction in efficacy as measured by serological response. An audit was undertaken to evaluate outcomes of the super- accelerated vaccine course in the first year of implementation.

Methods

A computer search of all coded entries relating to hepatitis B immunization from August 2002 to August 2003 was made. Data were collected from records of all patients commencing a course of super- accelerated hepatitis B vaccination. Data retrieval occurred three months after the time period of the study. The proportion of patients completing one, two and three vaccinations was identified. Outcomes were evaluated for those who had received a serological assessment at 12 weeks from commencement of vaccination. These patients were usually returning for repeat syphilis and HIV serology after the window period and hepatitis B surface antibody level was opportunistically measured. Comparison was made with the completion rates of a cohort of patients who commenced old schedule hepatitis B vaccination between January 2001 and January 2002 (injections at day zero, one and six months). These data were collected in December 2003 and included late opportunistic completion of vaccination after schedule dates.

Results

In all, 305 notes had a coding entry for hepatitis-related activity. One hundred and sixteen had vaccination commenced under the new schedule. One hundred and seventy-one had prior immunity or were continuing vaccination under the old schedule. Thirteen patients refused vaccination, four were not offered vaccination, and one set of notes was unavailable.

Of the 116 patients commencing vaccination, 11 (9.5%) had one injection, 21 (18.1%) completed two injections and 84 (72.4%) completed three injections. Comparison with the cohort from January 2001 to January 2002 is shown in Table 1.

Table 1 Comparison of completion rates for hepatitis B vaccination between standard and super-accelerated vaccination schedule

Table 2 Serological responses to super-accelerated vaccination schedule with associated factors

Patients attending for repeat serology for syphilis and HIV three months after initial attendance were also tested for hepatitis B surface antibody levels to monitor the serological response. A total of 39 patients had serological testing. The results of these tests are shown in Table 2.

Discussion

The outcome of this audit was encouraging. Using this vaccination schedule seemed acceptable to patients. Within the year under study and three months afterwards (when notes were pulled), 72.4% of those commencing vaccination completed three injections. This compares very favourably with 61.5% of those starting under the old schedule and completion rates of 56%1 and 71.4%2 reported by others. It also achieves the completion targets recommended by the National Strategy for Sexual Health and HIV, 50% by the end of 2004 and 70% by the end of 2006.3

Outcome of serological testing at three months after commencement of vaccination shows that 69.2% of patients already have a measurable anti-HBs antibody level of ≥ 10 U/L, with 48.7% having a measurable level of >100 U/L. This compares with reported levels at 49 days post third vaccine of 70.1% >10 U/L.4 In that study, by 365 days after initial vaccine, 92.9% of recipients of super-accelerated vaccine had anti-HB levels of ≥ 10 U/L.

Re-audit will help ensure that vaccination completion rates are maintained at least at this level. However, it may be difficult to meet any increase in targets for vaccine completion. Future audit may also look for reduction in the numbers of reattenders needing vaccination as more individuals accept vaccination at first attendance.

References

1 Jaleel H, Allan PS, Huensberg M, Natin D. Offering the vaccine and accepting it: an audit of hepatitis B vaccination in West Midlands region. Int J STD AIDS 2003;14:632-5

2 Openeye AA, Bashford J. Audit of hepatitis B immunization at the genitourinary medicine department in Middlesbrough, UK. Int J STD AIDS 2002;13:268-70

3 Department of Health. The National Strategy for Sexual Health and HIV. London: DoH, 2001

4 Marchou B, Excler J-L, Bourderioux C, et al. A 3-week hepatitis B vaccination schedule provides rapid and persistent protective immunity: a multicenter, randomized trial comparing accelerated and classic vaccination schedules. J Infect Dis 1995;172:258-60

(Accepted 25 August 2004)

O Jones BA MBBS and K N Sankar FRCP

Department of Genitourinary Medicine, Newcastle General Hospital, Westgate Road, Newcastle-upon-Tyne NE4 6BE, UK

Correspondence to: Dr K N Sankar

Email: nsankar@nhs.net

Copyright Royal Society of Medicine Press Ltd. Sep 2005