Abstract
Practice related to hepatitis B vaccination of men who have sex with men (MSM) in Scottish genitourinary medicine clinics was audited against targets based on the offer and completion of vaccination set by the British Association of Sexual Health and HIV. Of 521cases audited from 11 clinics, 215 (41%) were eligible for vaccination and 175 (81%) of eligible MSM were offered vaccination. Of those, 144 (82%) accepted vaccination. The super-accelerated schedule was most commonly prescribed but only 29% of those starting this schedule completed it, compared with 57% of those receiving the standard course. The overall vaccination completion rate was 31% and 82% of those completing vaccination had antisurface antibodies measured. A more robust recall system and uniformity in vaccination policies addressing the balance of patient compliance and immunogenicity of vaccine schedule are needed to improve completion rates.
INTRODUCTION
Hepatitis B vaccines have an excellent record of safety and studies have shown 95% efficacy in preventing acute and chronic infection in individuals at high risk of acquiring hepatitis B virus (HBV) infection, such as men who have sex with men (MSM). 1,2
The percentage of non-immune MSM attending Scottish genitourinary (GU) medicine clinics who commence vaccination is a key clinical indicator for monitoring health board performance.
3
National Health Service Quality Improvement Scotland (QIS) has decided that the proportion vaccinated should be at least 70%.
3
The British Association of Sexual Health and HIV (BASHH) guideline suggests the following audit standards:
2
Vaccination should be offered to all non-immune patients at ongoing risk (target 90%); All patients offered vaccination should be given a full course and should be tested for postvaccination response (target 50%).
To date there have been no published national audits on this topic. We compared performance of Scottish GU medicine clinics against these standards and each other.
METHODS
Between September 2006 and April 2007, external auditors (SR, KA and PS) visited each of the 11 main GU medicine clinics run by Scottish Health boards: Ayrshire, Argyll & Clyde, Grampian, Borders, Lothian, Fife, Greater Glasgow, Highland, Lanarkshire, Forth Valley and Tayside. Clinic staff utilized STISS (STI Surveillance Scotland), a secure web-based data collection system, to identify the patient records to be reviewed. Clinical notes of up to 100 MSM attending for a new episode of care between 1 July 2004 and 30 June 2005 were reviewed.
For each patient, the following data were recorded and analysed in Microsoft Excel: name of the clinic; date of clinic visit; age; eligibility for vaccination; whether vaccination was offered; response to offer; whether vaccination commenced; vaccination schedule used; total number of doses administered; whether course completed and postvaccination titres. For the purposes of the audit, a patient with no known history of prior or current hepatitis B (anti-HB core antibody and HB surface antigen negative) and no history of prior vaccination was considered eligible for vaccination.
RESULTS
The audit assessed a total of 521 MSM from 11 clinics. Each clinic contributed between 11 and 100 patients. Of the 521, 265 men (51%) had already completed vaccination, 20 (4%) were currently being vaccinated, 20 (4%) had natural immunity and one heterosexual man was excluded as his only risk factor for HBV infection was a sexual assault by a male five years ago. The remaining 215 patients (41%) were deemed eligible for vaccination.
Overall, 81% (175/215) of the eligible patients were offered vaccination. Only two of the 40 who were not offered vaccination had a documented reason, namely an isolated homosexual experience in otherwise heterosexual men. The acceptance rate among those offered vaccination was 82% (144/175). Of these, 137 had the first dose initiated at the time they were seen and it was documented that a further seven commenced vaccination within the next three months. Of the remaining 31 patients who were offered vaccination, nine declined, 20 said they would consider but had no record of commencing vaccination and two were subsequently vaccinated by their general practitioner.
Table 1 shows the uptake and completion of the various vaccination schedules. There was no defined vaccine schedule documented for eight patients of whom only two received at least three vaccine doses.
Dose completion of the different vaccination schedules
Vaccine schedule – *Day 0, 7, 21 and one year
†Zero, one, two months and one year
‡Zero, one and six months
NA = not applicable
The overall completion rate of vaccination was 31% (45/144). Eighty-two percent (37/45) of the patients who completed vaccination subsequently had titres measured.
DISCUSSION
Of eligible MSM, 81% were offered vaccination, almost achieving the suggested BASHH target of 90%. Sixty-seven percent (144/215) of non-immune men commenced vaccination and the QIS standard of 70% was almost met. The overall uptake rate of vaccination was high (82%) reflecting patient acceptability.
The super-accelerated course has previously been shown to be most convenient for patients as the initial three doses are administered over a brief three-week period thus improving compliance. 3 However, here a large proportion of patients failed to return for their fourth dose a year later.
Our overall completion rate (31%) was lower than the suggested target of 50%. The policy in some clinics (perhaps due to a misinterpretation of the BASHH guideline) 2 was to measure antisurface antibody titres 4–6 weeks after the third dose of the super-accelerated schedule and only administer the fourth dose to those with unsatisfactory titres. The fourth dose is not optional as although the completion of the first three doses of the super-(accelerated) schedule produces rapid seroprotection, its efficacy in conferring long-term immunity is yet to be established. 3,4
Most patients (75% [79/106]) receiving the super-(accelerated) regimens in this audit completed at least three doses, a similar rate to that reported by other groups. 5–8 The National Strategy for Sexual Health and HIV audit standard for hepatitis B vaccination in eligible MSM is at least 50% uptake of three vaccine doses. 9 This was synonymous with ‘completed vaccination’ in the past when the standard three-dose schedule was most frequently prescribed but does not apply to four-dose regimens. The use of the super-accelerated schedule has superceded that of the standard schedule and therefore audit standards should be revised to include fourth dose uptake and perhaps the target of 50% be reviewed.
As some clinics move to electronic patient records, completion rates may be improved by automatic reminders being sent to those failing to complete vaccination. Our audit has identified the need for clear and uniform hepatitis B vaccination guidelines that balance the immunogenicity of the vaccine schedule used and the likely adherence of patients.