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Hepatitis B Vaccination of Men Who Have Sex With Men: Experience With an Accelerated Course of Vaccination in a Genitourinary Medicine Clinic

Posted on: Saturday, 8 October 2005, 03:01 CDT

By McMillan, A

Summary: An accelerated course of hepatitis B vaccination was offered to men who had sex with men attending a genitourinary medicine clinic. The uptake and completion rates of the vaccine between 1 November 2002 and 28 February 2004 were compared with data for 1994. The uptake of vaccine was significantly higher during the former audit period than the latter (310 [98%] of 315 versus 146 [74%]). There was, however, no significant difference in completion rates between the two audit periods: 220 (73%) of the 302 men who initiated the accelerated schedule, compared with 118 (81%) of the 146 men who completed the standard course in 1994. Innovative means of ensuring completion of vaccination are needed.

Keywords: hepatitis B vaccination, men who have sex with men

Introduction

Although vaccination is effective in reducing the risk of hepatitis B virus (HBV) infection among men who have sex with men (MSM),1 most studies have shown that fewer than 75% (in some studies only about one-fifth) complete the standard course of three injections given over a six-month period.2-6 The rather protracted nature of the vaccination schedule might be a factor in determining whether or not an individual will complete the course of vaccine, although this hypothesis has not been fully explored in reported studies. An accelerated vaccination schedule for rapid protection against hepatitis A and B has been described.7 Doses of combined hepatitis A and B vaccine (Twinrix, Glaxo SmithKline, Belgium) are given on days 0, 7 and 21, with a booster dose administered 12 months later. About 95% of vaccinees develop protection against hepatitis B within three months of completion of the primary vaccination schedule.7

The accelerated course of vaccination against hepatitis A and B was introduced into the Edinburgh clinic protocol in November 2002. The aim of this paper is to describe the acceptance of this vaccination schedule among MSM, and to compare the results with those of the standard schedule as shown in a previous unpublished audit.

Methods

The two audit periods were (1) between 1 January 1994 and 31 December 1994, and (2) between 1 November 2002 and 28 February 2004. MSM who attended the Department of Genitourinary Medicine, Edinburgh Royal Infirmary, were identified from the clinic database for these periods, and their case-notes were retrieved manually. Note was made of the patient's age, postcode (2002-2004 only), the number of injections of hepatitis vaccine administered, and the results of serological testing for current or past infection with HBV.

The Amerlite system (Ortho Diagnostic Systems, Germany) was used for the detection of hepatitis B surface antigen (HBsAg) and of core antibody (anti-HBc).

During the first audit period, the clinic policy was to offer vaccination against hepatitis B to MSM who had not been vaccinated previously and who had no pre-existing immunity to HBV (anti-HBc negative). The serological status was determined from a blood sample obtained at the patients' initial attendance. An appointment was given to re-attend the clinic about 14 days later and the first dose of monovalent hepatitis B vaccine (Engerix B) was given to eligible patients. The second and third were given one and six months after the first dose.

During the second audit period, a combined hepatitis A and B vaccine (Twinrix) was offered to all MSM who had not been vaccinated previously. The first dose, which was given before the results of serological testing were available, was given at the patient's first clinic visit, and appointments were made for attendance seven and 21 days later for the second and third doses. When there was pre- existing immunity to hepatitis A, only monovalent hepatitis B vaccine was used in the second and subsequent dosing. The nurses who administered the vaccine emphasized the importance of completion of the course.

The χ^sup 2^ test with Yates' correction and the Mann- Whitney U-tests were used in the analysis of the categorical and numerical data, respectively.

Only hepatitis B vaccination is considered in the current audit.

Results

During the first audit period, 500 MSM attended the Department; 197 (39%) were eligible for vaccine. Of the 197 men, 51 (26%) declined vaccination, were not offered vaccine, or defaulted from the first follow-up visit.

During the second audit period, 921 MSM attended the Department; 315 (33%) were initially considered eligible for hepatitis B vaccination; three men declined vaccination, two men were not offered vaccine, and eight men were subsequently shown to be anti- HBc positive. The uptake of vaccination was significantly greater during the second audit period than the first (χ^sup 2^ = 71.0; P < 0.0001).

There was no significant difference between the two audit periods in the median ages of men who initiated vaccination (median ages [interquartile range - IQR] in 1994 and second audit period 27.0 [9.0] years and 25.0 [13.0] years, respectively; P>0.05).

Figure 1a and b shows the number of eligible MSM who attended for the second and third doses of vaccine. There was no significant difference between the two audit periods in the proportions of men who received the second and third doses of vaccine (χ^sup 2^ = 2.08 and 2.96, respectively; P>0.05 in both instances).

Men who did not attend for the second dose of the accelerated course of vaccine were significantly younger than those who did attend (median age 23.0 years [IQR 7.0 years] versus 25.5 [IQR 13.0 years]; P = 0.01). There was no significant difference in the median ages between those who attended for the third dose and those who defaulted (26.0 years [IQR 11.0 years] and 24.0 years [IQR 13.0 years], respectively; P>0.05).

There was no difference in the proportions of men who received all three doses of the accelerated vaccine between those who had an address in the City of Edinburgh (EH01-EH17) and those who did not (177 of 240 versus 43 of 62 men; χ^sup 2^ = 0.28, P>0.05). Four men did not supply an address. Similarly, there was no difference in these parameters among men who received or did not receive the second dose of vaccine (209 of 240 versus 55 of 62; χ^sup 2^ = 0.02, P>0.05).

Figure 1 (a) Uptake by MSM (men who have sex with men) of hepatitis B vaccine during 1994. (b) Uptake by MSM of hepatitis B vaccine between December 2002 and February 2004

Discussion

This study has shown that among MSM attending the Edinburgh clinic, the uptake of hepatitis B vaccination has improved dramatically. The completion rate, however, has not changed significantly with the introduction of the accelerated vaccination schedule.

Several studies have shown significant correlates of uptake of hepatitis B vaccination among MSM. These include younger age, living in an urban setting, educational level, knowledge about HBV vaccine, sexual openness, and a limited number of lifetime sexual partners.8 Negative correlates of vaccination have included more than 20 lifetime sexual partners, injection drug use, and a perception of being at low risk for HBV infection. In one of the few studies on lack of completion of hepatitis B vaccination among MSM, having unprotected sexual intercourse, multiple sexual partners and accepting money, drugs or gifts for sex were identified as factors.9 In the present study, men who defaulted from the second dose of vaccine were significantly younger than those who received this dose. None of the patients had a history of injecting drug use. As the number of lifetime sexual partners was not always recorded, it is impossible to correlate lack of completion of vaccination with this parameter. Similarly, an association with the acceptance of gifts for sex cannot be determined.

As the clinic is centrally situated in the City of Edinburgh, and as there was no significant difference in completion rates between those men living centrally and those who lived further from the clinic, lack of completion of the course of vaccine cannot be attributed to the geographical location of the unit.

It is clear that further research into the reasons for failure of completion of hepatitis B vaccination is required, and that innovative means of ensuring complete vaccination are needed.

References

1 Szmuness W, Stevens CE, Zang EA, Harley EJ, Kellner A. A controlled clinical trial of the efficacy of the hepatitis B vaccine (Heptavax B): a final report. Hepatology 1981;1:377-85

2 Bhatti N, Gilson RJC, Beecham M, et al. Failure to deliver hepatitis B vaccine: confessions from a genitourinary medicine clinic. BMJ 1991;303:97-101

3 Yuan L, Robinson G. Hepatitis B vaccination and screening for markers at a sexually transmitted disease clinic for men. Can J Public Health 1994;85:338-11

4 Weinstock HS, Bolan G, Moran JS, Peterman TA, Polish L, Reingold AL. Routine hepatitis B vaccination in a clinic for sexually transmitted diseases. Am J Public Health 1995;85:846-9

5 Neighbors K, Oraka C, Shih L, Lurie P. Awareness and utilization of the hepatitis B vaccine among young men in the Ann Arbor area who have sex with men. J Am Coll Health 1999;47:173-8

6 Sansom S, Rudy E, Strine T, Douglas W. Hepatitis A and B vaccination in a sexually transmitted disease clinic for men who have sex with men. Sex Transm Dis 2003;30:685-8

7 Nothdurft HD, Dietrich M, Zuckerman JN, e\t al. A new accelerated vaccination schedule for rapid protection against hepatitis A and B. Vaccine 2002;20:1157-62

8 Yee LJ, Rhodes SD. Understanding correlates of hepatitis B virus vaccination in men who have sex with men: what have we learned? Sex Transm Infect 2002;78:374-7

9 Dufour A, Remis RS, Alary M, et al. Factors associated with hepatitis B vaccination among men having sexual relations with men in Montreal, Quebec, Canada. Sex Transm Dis 1999;26:317-24

(Accepted 29 July 2004)

A McMillan MD FRCP

Department of Genitourinary Medicine, NHS Lothian, University Hospitals Division, Lauriston Building, 39 Lauriston Place, Edinburgh EH3 9HA, UK

Email: a.amcmm@btopenworld.com

Copyright Royal Society of Medicine Press Ltd. Sep 2005

Source: International Journal of STD & AIDS

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