GPs' college issues guidance on hepatitis A and B vaccination
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7491.558-c (Published 10 March 2005) Cite this as: BMJ 2005;330:558All rapid responses
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Dear Editor
""All drug users should be vaccinated with hepatitis B vaccine because non-injectors often became injectors."" (R. Short 2005)
This quote, a restatement of the “escalation” hypothesis, is one step further from what is stated in the excellent guidance for vaccination of IDU with hepatitis A and B vaccinations in Primary Care. The guide actually states, “Vaccinate all drug users against hepatitis B (non- injectors may become injectors)” ( Coffey and Young 2005).
The so called "escalation" hypothesis or "gateway theory" i.e. using any drugs, including cannabis, will lead to the use of heroin and by implication by injection is often popular with politicians but is far from being evidence based (Drugscope 2003). On the contrary S. Pudeny concluded that there is "no significant impact of soft drug use on the risk of later involvement with crack and heroin." (Pudney 2002)
Surveys suggest that over a quarter (25.4%) of 16 to 29 have used any drugs in the past 12 months, of which 22.7% used cannabis only (National Statistics 2001). As such it is very fortunate that few “drug users” go on to become injecting users. A point I am sure that previous cabinet ministers and even former, non-inhaling, USA Presidents would confirm.
Vaccinating a quarter of young people would probably be a “good thing” in itself, but then again vaccinating them all would be even better, a point not lost on the WHO. The WHO has called for population based Hepatitis B vaccination campaign for children since 1991 with 116 countries reportedly having already added this to their routine vaccination programme (WHO 2005).
The clear case for vaccinating IDU’s for Hepatitis A and B should not be used as a platform for restating spurious statements based on the “escalation” hypothesis.
Chris Lovitt
References
1) R Short (2005) GPs' college issues guidance on hepatitis A and B vaccination BMJ 2005;330:558 (12 March), http://bmj.bmjjournals.com/cgi/content/full/330/7491/558-c (accessed March 2005)
2) E Coffey & D Young (2005) Guidance for hepatitis A and B vaccination of drug users in primary care and criteria for audit
3) Drugscope (2003) "Does cannabis use lead to taking other drugs" http://www.drugscope.org.uk/druginfo/drugsearch/faq_template.asp?file=\wip\11\1\2\cannabis.html (accessed March 2005)
4) S Pudney (2002) " The Road to ruin- Sequences of initiation into drug use and offending by young people in Britain"- Home Office http://www.homeoffice.gov.uk/rds/pdfs2/hors253.pdf (accessed March 2005)
5) National Statistics 2001 "Drug use among 16 to 29 year olds, 2001/02: Regional Trends 38" http://www.statistics.gov.uk/STATBASE/ssdataset.asp?vlnk=7806 (accessed March 2005)
6) WHO (2005) Hepatitis B http://www.who.int/mediacentre/factsheets/fs204/en/ (accessed March 2005)
Competing interests: None declared
Competing interests: No competing interests
Guidance for hepatitis A and B vaccination of drug users in Primary Care
Editor
Promotion of the Royal College of General Practitioners' guidance on vaccination of drug users against hepatitis A and hepatitis B in Primary care (1) is to be welcomed, but it is disappointing that the news roundup article by Short (2) failed to emphasise a fundamental principle of the guidance, namely that vaccination needs to be carried out opportunistically and that a pragmatic approach to vaccination schedule should be adopted in this hard to reach group.
Short states that "the accelerated schedule for hepatitis B vaccination should be used, under which the vaccination is given at 0,7 and 21 days". In fact, two 'accelerated schedules' are recommended in the guidelines - 0, 1 and 2 months or 0,7 and 21 days - the latter schedule is sometimes referred to as 'super-accelerated' and, according to the guidance, is promoted by the Department of Health for use in prisons.
By failing to mention the first accelerated schedule, Short gives a misleading and potentially dangerous summary of the guidance. The 0,1 and 2 month schedule is particularly suitable for Primary Care as it allows the vaccine to be administered opportunistically at appointments made for substitute prescribing. Drug Users are much more likely to attend an appointment at which a prescription is issued, and General Practitioners are more likely to take on workload that is more realistically spaced.
Regarding hepatitis A vaccination, Short states that the single hepatitis A vaccine should be given and that the combined A and B vaccine is not recommended. This is misleading. The guidance simply states that one dose of hepatitis A vaccine confers greater protection against hepatitis A than one dose of the combined vaccine, and that the likelihood of the drug user returning for a subsequent dose should be taken into account when selecting either the single or combined vaccine. The guidelines actually give three recommended schedules of hepatitis A and B vaccines (table two) - Single, Routine combined and Accelerated combined. In my experience, many drug users have an almost inexplicable aversion to injections, and the combined vaccine (one injection per visit) may well be the only acceptable alternative for an individual requiring protection against hepatitis A and hepatitis B.
The guidance is intended for use in Primary Care, and previous research has shown that an appropriate vaccination schedule for primary care should be flexible to maximise compliance (3). I appreciate that the news roundup article presented only a brief summary of the guidance, but failure to reflect the fact that a number of vaccination schedules are recognised as appropriate misses the opportunity to encourage General Practitioners to concentrate on 'getting the needle into the arm' and thereby tackle this important public health problem (4).
Nigel Williams
References
(1) Coffey E and Young D. Guidance for hepatitis A and B vaccination of drug users in primary care and criteria for audit. RCGP Drug Misuse Training Programme, RCGP Sex, Drugs and HIV Task Group, SMMGP. First Edition, 2005.
(2) Short R. GPs' college issues guidance on hepatitis A and B vaccination. BMJ 2005; 330: 558-c..
(3) Budd J, Robertson R, Elton R. Hepatitis B vaccination and injecting drug users. British Journal of General Practice 2004, 54, 444- 447.
(4) Department of Health. Prevalence of HIV and hepatitis infections in the United Kingdom. Annual report of the Unlinked Anonymous Prevalence Monitoring Programme. London: Department of Health, 2002.
Competing interests: None declared
Competing interests: No competing interests