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July 22, 1996

At-Risk Populations; Chronic HCV Patients Should Receive HBV Vaccine

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, 1996;312:1336-1337).

"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 professionals."

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 risk.

"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 2QQ.

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