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Prospective study of hepatitis B vaccination in patients with chronic hepatitis C

^a Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's NHS Trust, Cambridge CB2 2QQ, ^b Department of Virology, Addenbrooke's NHS Trust

Correspondence to: Dr Alexander.

Chronic hepatitis C results in liver disease, cirrhosis, and hepatocellular carcinoma. Its prevalence is estimated to be 70-92% among intravenous drug misusers,¹ who are also at risk of parenterally or sexually transmitted hepatitis B. Coinfection with hepatitis B virus may accelerate underlying liver damage due to hepatitis C.²

Effective vaccines against hepatitis B have been available for a decade.³ Universal vaccination is being adopted in countries where hepatitis B is common. When vaccination has been targeted at promiscuous people and intravenous drug misusers uptake has been suboptimal and the incidence of hepatitis B has increased.^{4 5} We therefore investigated whether carriers of hepatitis C were being vaccinated against hepatitis B.

Patients, methods, and results

We prospectively studied 126 consecutive patients attending our hepatology clinic who had positive results for antibodies to hepatitis C virus in two second generation enzyme linked immunoassays (ELISAs; Murex Diagnostics, Dartford, and Sanofi Diagnostic Pasteur, Guildford). Their median age was 38 years, and 86 were men. We 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 knew that 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 Amerlite assays (Johnson and Johnson Diagnostics, Amersham).

Eighty eight patients were intravenous drug misusers, 22 had been exposed to blood or blood products, and 16 had no identifiable risk factor. Table 1 shows the results of serological tests for hepatitis B. Seventy five patients were negative for all serum markers of hepatitis B and were therefore still at risk; 52 of them had a history of drug misuse. 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 this clinic. Only nine of the 126 patients said that they had been advised to be vaccinated because of the risk of hepatitis B, and seven had followed this advice. Three further patients had been vaccinated because of travel or occupational risk.

Table 1--Results of tests for hepatitis B markers in 126 patients with chronic hepatitis C
---------------------------------------------------------------------------------------------------
                                                             No of
                                                            patients           Comment
---------------------------------------------------------------------------------------------------
Hepatitis B surface antibody alone                              3         All were vaccinated
Hepatitis B surface antibody and hepatitis B core antibody     12          7 were vaccinated
Hepatitis B core antibody alone                                33
Hepatitis B core antibody and hepatitis B surface antigen       2
Hepatitis B surface antigen alone                               1
No marker                                                      75     52 had history of intravenous
                                                                              drug misuse

Comment

In this series 41% of patients had been infected with hepatitis B (51/126), confirming the risk in carriers of hepatitis C. Only 7% (9/126) 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 behaviour among intravenous drug misusers, despite educational programmes. This population is difficult to identify in the community, and people who misuse intravenous drugs rarely approach healthcare professionals about vaccination. Sexual transmission of hepatitis B has increased in the United States, and the incidence of infection among misusers and their sexual contacts has probably increased.⁵

Our results suggest that opportunities for vaccination are being missed. The reasons that vaccination might not have been offered include a failure to recognise that patients with hepatitis C are at risk of hepatitis B and a failure to appreciate that intravenous drug misusers have inconsistent contact with health care professionals. 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 NHS in preventing acute or chronic hepatitis B undoubtedly offsets the costs of vaccination.

Patients with chronic hepatitis C who are at risk of hepatitis B should be offered vaccination at their first contact with health care professionals.

Funding: None.

Conflict of interest: None.

1. Esteban R. Epidemiology of hepatitis C virus infection. J Hepatol 1993;17:567-71.
2. Ilan Y, Ashuv Y, Tur-Kaspa R, Shouval D. Chronic hepatitis C virus infection with exposure to to hepatitis B virus. Isr J Med Sci 1994;30:259-63. [Medline]
3. Catterall AP, Murray-Lyon IM. Strategies for hepatitis B immunisation. Gut 1992;33:576-9. [Free Full Text]
4. Centers for Disease Control, US Department Health and Human Services, Atlanta, Georgia. Update on Hepatitis B Prevention 1987;107:353-7.
5. Alter MJ, Hadler SC, Margolis HS, Alexander WJ, Hu PY, Judson SN, et al. The changing epidemiology of hepatitis B in the United States. JAMA 1990;263:1218-22. [Abstract/Free Full Text]

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