Hepatitis B vaccination targeted at behavioural risk groups in the Netherlands: Does it work?

doi:10.1016/j.vaccine.2009.03.072

Vaccine

Volume 27, Issue 27, 2 June 2009, Pages 3530-3535

https://doi.org/10.1016/j.vaccine.2009.03.072 Get rights and content

Abstract

In November 2002, the Netherlands adopted a vaccination program targeted at behavioural risk groups. Between January 2003 and December 2007, 1386 patients acutely infected with HBV were reported. Reported cases declined from 326 in 2003 to 220 in 2007. Sexual intercourse was the most frequently reported mode of transmission (65%), especially among men having sex with men. Genotypes A and D remained predominant. In total, 40,600 participants were fully vaccinated, the overall compliance was 62%, and the estimated overall program coverage was 12% of the at-risk population. With more effort, more susceptibles may be reached, but the program will not be sufficient to substantially reduce HBV in the Netherlands. Therefore, universal vaccination should be considered.

Introduction

Hepatitis B virus (HBV) infections and the consequent increased risk for chronic infection with its sequelae cirrhosis and hepatocellular carcinoma can be prevented by a safe and effective vaccine. The WHO has advised worldwide universal vaccination since 1992, not only in countries where HBV is highly endemic but also in low-endemic countries [1].

The Netherlands is a low-endemic country with an estimated HBsAg prevalence of 0.3–0.5% [2], where HBV transmission is restricted mainly to risk groups. Therefore, the Netherlands, like Britain, and the Scandinavian countries, has adopted a policy of vaccination targeted at behavioural risk groups, rather than universal vaccination [3]. This targeted program was implemented in November 2002, after a pilot of 2 years that was conducted in several regions of the Netherlands to investigate its feasibility [4], [5]. Within the program, commercial sex workers (CSWs), hard drug users (DUs), and men having sex with men (MSM) are vaccinated free of charge at their local Public Health Service and at clinics that treat sexually transmitted infections (STI). Furthermore, various outreach strategies are tailored to these risk groups. Until October 2007, heterosexuals with an indication for an STI exam were also considered a risk group and therefore vaccinated.

Before implementation of this targeted vaccination program, HBV prevention in the Netherlands consisted mainly of prenatal screening and vaccination of newborns with a chronically infected mother, vaccination of certain patient groups (e.g. hemophiliacs), and healthcare workers. These preventive measures are still ongoing and were extended with the targeted vaccination program and with the vaccination of newborns with at least one parent born in a country with a HBV prevalence over 2%, as of 2003.

Since the Netherlands did not implement universal HBV vaccination, it is important to monitor the effect of our current strategy targeted at behavioural risk groups. Such an evaluation may have implications for countries with a comparable vaccination strategy and even for countries with a universal vaccination program, since they have the same risk groups.

The pilot study preceding nationwide implementation of the vaccination program targeted at behavioural risk groups reached only a small number of people, most of whom were vaccinated in Amsterdam [4], [5]. As Amsterdam is not representative for the rest of the Netherlands, we have evaluated the current risk group vaccination program 5 years after implementation, using nationwide epidemiological data of reported HBV cases and national vaccination data. Only acute cases were included in this study, because they give insight in the evolution of HBV transmission in the Netherlands. Molecular epidemiology was used to obtain insight into the impact of this targeted vaccination program, and on the dynamics of HBV transmission between and amongst behavioural risk groups and the general population.

Section snippets

Patients

In the Netherlands, all cases of HBV infection have to be reported to the local Public Health Service and subsequently to the National Centre of Infectious Diseases Control. The reporting criteria for acute HBV are: clinical signs and symptoms of acute hepatitis in combination with the presence of HBsAg in the serum. Reported patients are approached by public health nurses for source and contact tracing and for information about the most likely mode of infection. These data are stored in the

General characterization of acute HBV cases

From January 2003 through December 2007, 1386 patients acutely infected with HBV were reported in the Netherlands. Of these, 78% were men. The annual number of reported cases declined from 326 in 2003 to 220 in 2007, equivalent to a decline in reported incidence from 2.0 to 1.4 per 100,000 inhabitants. Based on interviews with public health nurses, patients were classified according to the most probable mode of transmission (Table 1). For both men and women sexual intercourse was the most

Discussion

In November 2002, the Netherlands adopted a HBV vaccination program targeted at behavioural risk groups, instead of implementing a universal vaccination program. Five years after its implementation, the total number of reported patients acutely infected with HBV has declined from 326 in 2003 to 220 in 2007 and has returned to the level of the 1990s. This decline could be observed in all risk groups. The largest decline was seen among MSM, although it was not significantly larger than in other

Acknowledgements

The authors thank J.A.R. van den Hoek, B.A. Wolters, C.J.P.A. Hoebe, A. Gadiot, S. Esman, H.M. Götz, S. Feenstra-van Gols, J. Sleven, P.B.G. ten Ham, M. Hosseinnia, P.H.A. Jacobs, A. van Heukelum, H. van den Kerkhof, J.T. Versteegen, M.F. Siebbeles, R. van Kessel, M. Besselse, A.G. Kraaijeveld, R.P.M. Koene, D. van der Werf, E. Lodder, R. ter Schegget, E. van Dijk, M.G.E. Hottinga, J.J. Tiessen, E.J.M. de Coster, J.M.C. de Vries, B. Hoendermis, E. Rood, S.L. Lie, R. van Essen, L. Helmhout, G.

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Citation Excerpt :
Our findings have important policy implications. Previous evaluations of this programme up to 2006 (incidence trend analysis, mathematical modelling and molecular sequence models) could prove no impact [22–24]. Concern also exists about the effectiveness of such programmes when the uptake or coverage remains low [25,26], and in the past the programme aimed at including as many MSM possible.
In the Netherlands, transmission of hepatitis B virus occurs mainly within behavioural high-risk groups, such as in men who have sex with men. Therefore, a vaccination programme has targeted these high-risk groups. This study evaluates the impact of the vaccination programme targeting Amsterdam’s large population of men who have sex with men from 1998 through 2011.
We used Amsterdam data from the national database of the vaccination programme for high-risk groups (January 1, 1998 to December 31, 2011). Programme and vaccination coverage were estimated with population statistics. Incidence of acute hepatitis B was analyzed with notification data from the Amsterdam Public Health Service (1992–2011). Mathematical modelling accounting for vaccination data and trends in sexual risk behaviour was used to explore the impact of the programme.
At the end of 2011, programme coverage was estimated at 41% and vaccination coverage from 30% to 38%. Most participants (67%) were recruited from the outpatient department for sexually transmitted infections and outreach locations such as saunas and gay bars. Incidence of acute hepatitis B dropped sharply after 2005. The mathematical model in which those who engage most in high-risk sex are vaccinated, best explained the decline in incidence.
Transmission of hepatitis B virus among Amsterdam’s men who have sex with men has decreased, despite ongoing high-risk sexual behaviour. Vaccination programmes targeting men who have sex with men do not require full coverage; they may be effective when those who engage most in high-risk sex are reached.
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Citation Excerpt :
An important finding of evaluation studies is that these intensive vaccination campaigns nevertheless failed to reach a large part of the behavioural high-risk groups [4]. Estimates of the vaccination coverage among MSM varied from 12% in Amsterdam to about half that percentage for the rest of the country [6,10]. Allowing for the fact that a substantial number of those in the high-risk groups is already infected and therefore would no longer benefit from vaccination, it was estimated that more than half of the members of behavioural high-risk groups still run the risk of contracting hepatitis B [6].
WHO have long called for universal vaccination against hepatitis B worldwide. However, in north-western Europe low incidence of the disease has fueled debate whether targeted or universal vaccination strategies are the way to go for. Careful assessment has made it clear that the extensive targeted hepatitis B vaccination programmes in the Netherlands nevertheless fail to reach a significant part of the risk groups and have not succeeded in eliminating the disease. Modelling suggests that the public health benefits obtained through targeted programmes could be augmented considerably by universal vaccination. Therefore, the Minister of Health of the Netherlands has decided to implement universal vaccination by October 2011. We illustrate the case of the Netherlands and explore lessons, which can be learnt from the vaccination programmes against HPV and influenza A/H1N1 and how to prepare for a potential public debate that might arise when implementing universal vaccination against hepatitis B.
Hepatitis B vaccination coverage among high-risk adults 18-49 years, U.S., 2009
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Approximately 43,000 new hepatitis B virus (HBV) infections occurred in 2007. Although hepB vaccination has been recommended for adults at high-risk for incident HBV infection for many years, coverage remains low.
We used the 2009 National Health Interview Survey to assess self-reported HepB vaccine uptake (≥1 dose), series completion (≥3 dose), and independent predictors of vaccination among high-risk adults aged 18–49 years. High-risk adults were defined as those reporting male sex with men; injection drug use; hemophilia with receipt of clotting factors; sexually transmitted disease in prior five years; sex for money or drugs; HIV positive; sex with persons having any above risk factors; or who “felt they were at high risk for HIV”. Persons with none of the aforementioned risk factors were considered non-high risk. Bivariate analysis was conducted to assess vaccination coverage. Independent predictors of vaccine uptake and series completion were determined using a logistic regression.
Overall, 7.0% adults aged 18–49 years had high-risk behaviors. Unadjusted coverage with ≥1 dose was 50.5% among high-risk compared to 40.5% among non-high-risk adults (p-values <0.001) while series completion (≥3 doses) was 41.8% and 34.2%, respectively (p-values <0.001). On multivariable analysis, ≥1 dose coverage, but not series completion, was higher (Risk Ratio 1.1, 95% CI = 1.0–1.2, p-value = 0.021) among high-risk compared to non-high risk adults. Other characteristics independently associated with a higher likelihood of HepB vaccination among persons 18–49 years included younger age groups, females, higher education, ≥2 physician contacts in the past year, ever tested for HIV, health care personnel, received influenza vaccination in the previous year, and ever received hepatitis A vaccination. Vaccine uptake with ≥1 dose increased by 5.1% (p = 0.047) among high-risk adults between 2004 and 2009.
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Hepatitis B vaccination targeted at behavioural risk groups in the Netherlands: Does it work?

Abstract

Introduction

Section snippets

Patients

General characterization of acute HBV cases

Discussion

Acknowledgements

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