July 22, 1996
At-Risk Populations; Chronic HCV Patients Should Receive HBV
Antiviral Weekly via Individual Inc. : Patients with chronic
hepatitis C who are at risk for hepatitis B should be offered
vaccination during their first contact with healthcare
professionals, according to a report from Great Britain's
University of Cambridge.
"Our results suggest that opportunities for vaccination are
being missed," researcher Voishim Wong and colleagues wrote
("Prospective Study of Hepatitis B Vaccination in Patients with
Chronic Hepatitis C," British Medical Journal, May 25,
"The reasons that vaccination might not have been offered
include a failure to recognize that patients with hepatitis C are
at risk of hepatitis B and a failure to appreciate that intravenous
drug misusers have inconsistent contact with healthcare
Chronic hepatitis C (HCV) infection is estimated to occur in
between 70- and 92 percent of intravenous drug users. These IV drug
users are also at risk for parenterally or sexually transmitted
hepatitis B. Coinfection with hepatitis B virus (HBV) may
accelerate underlying liver damage due to hepatitis C. "When
vaccination has been targeted at a promiscuous people and
intravenous drug misusers, uptake has been suboptimal and the
incidence of hepatitis B has increased," Wong et al. wrote. "We
therefore investigated whether carriers of hepatitis C were being
vaccinated against hepatitis B."
The researchers prospectively studied 126 consecutive patients
attending a hepatology clinic who had positive results for
antibodies to HCV in two second generation enzyme linked assays
(ELISAs). Their median age was 38 years, and 86 were men.
Wong et al. documented demographic details including risk
factors. Each patient was asked about the number of health service
workers with whom they had had contact since they learned they were
positive for antibody to hepatitis C virus and whether they had
been advised to be vaccinated against hepatitis B. Hepatitis B
surface antigen, hepatitis B surface antibody, and hepatitis B core
antibody were measured in Amerilite assays.
Eighty-eight patients were IV drug users, 22 had been exposed to
blood or blood products and 16 had no identifiable risk factor. A
total of 75 patients were negative for all serum markers of
hepatitis B and were therefore still at risk; 52 of these patients
had a history of IV drug use.
None of the 75 patients had been offered vaccination, though
they had seen an average of two doctors (range 1-4) and other
healthcare professionals between being diagnosed as having
hepatitis C and attending the clinic. Only nine of the 126 patients
said they had been advised to be vaccinated because of the risk of
hepatitis B, and seven had followed this advice. Three other
patients had been vaccinated because of travel or occupational
"In this series 41 percent of patients had been infected with
hepatitis B (51/126), confirming the risk in carriers of hepatitis
C," Wong et al. wrote. "Only 7 percent (nine of 126) had been
offered vaccination, although hepatitis B could have been prevented
by this approach. Despite having contact with health workers, our
patients said that they had not been advised about vaccination -
though it may have been offered.
"Little change has been observed in high risk behavior among
intravenous drug misusers, despite educational programs. This
population is difficult to identify in the community, and people
who misuse intravenous drugs rarely approach healthcare
professionals about vaccination... . Some healthcare professionals
may believe that vaccination is not their primary responsibility.
Cost is unlikely to be an important issue as the vaccine is
comparatively cheap and the current potential cost saving for the
National Health Service in preventing acute or chronic hepatitis B
undoubtedly offsets the costs of vaccination."
The corresponding author for this study is Graeme J.M.
Alexander, Department of Medicine, University of Cambridge School
of Clinical Medicine, Addenbrook's NHS Trust, Cambridge, CB2
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