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Promoting hepatitis B immunisaton Plain English Campaign approved the clarity of this guide, and the campaign materials that go with it. Strategies for improving delivery of hepatitis B immunisation Bibliography and further reading
Introduction Hepatitis B is preventable with a simple course of three immunisations. Despite longstanding calls for the promotion of hepatitis B immunisation amongst injecting drug users, at the time of writing many of them are still not being offered immunisation, or even being told that it exists. This guide and the materials that accompany it are designed to help change this situation. This briefing is intended to give professionals working with drug users the tools to implement some of the essential interventions which lie at the heart of harm reduction. Hepatitis B immunisation prevents not just one, but two blood-borne viral infections, as it also protects those who receive it against hepatitis D. This is because hepatitis D is an ‘incomplete’ virus that can only replicate in the presence of hepatitis B. For the strategy of vaccinating high-risk groups to be as effective as possible, services in contact with injecting drug users and others at risk, have to find effective ways of ensuring that:
This guide gives information on:
The hepatitis B virus
Transmission of hepatitis B infection can occur through:
Hepatitis B can cause serious liver disease. The majority of adults (85% to 90%) infected by the virus will clear it after a short (occasionally severe) illness and usually gain lifelong immunity. However, the remaining 10% to 15% of people may continue to be infectious indefinitely and will be at greatly increased risk of developing cirrhosis and liver cancer. For people infected with both hepatitis B and hepatitis C the risk of serious liver disease is much higher. There has not been any widespread blood testing of the kind that could accurately establish the prevalence of hepatitis B. Such testing could allow for appropriate advice on:
However, available UK surveys show that 20% to 30% of injecting drug users in contact with treatment services show evidence of current or past hepatitis B infection. This means that through immunisation hepatitis B can be prevented in the majority of the remaining 70% to 80% of injecting drug users. Hepatitis B immunisation
However, high levels of success are clearly possible, as are indicated by the service examples below:
The Drug Action Team (DAT) template (1999 - 2000) states that 51% of DAT areas have a hepatitis B immunisation programme in place, with the remaining 39% reporting that a programme was planned. At risk groups
Immunisation schedules The accelerated immunisation schedule consists of:
Over six months the schedule is:
A complete course of the vaccine will give good long-term protection to around 95% of people. Even one dose of the vaccine may be enough to give immunity in some individuals. Approximately 5% of the adult population do not respond to the vaccine and do not develop immunity. Injecting drug users may be less likely to develop effective immunity than the general population. Factors such as cigarette smoking are thought to make vaccination less likely to be successful. Vaccine safety Of the very rare undesirable effects, anaphylaxis (a life-threatening allergic reaction) is extremely rare, with a likely occurrence of just 1 in 600,000 injections. The possibility of anaphylaxis is sometimes given as a reason for only vaccinating for hepatitis B when resuscitation equipment and staff trained in its use are present. However, the extreme rarity of anaphylaxis, means that it is possible to devise local protocols, in a variety of settings, that allow non-medical staff to give this life saving immunisation (following appropriate training), under the supervision of a medical practitioner. The risks of hepatitis B infection, especially to those who already have hepatitis C, mean that the very small risks associated with immunisation are far outweighed by the benefits - which can be life-saving. Hepatitis B blood tests had previous exposure to the hepatitis B virus by testing for antibodies to hepatitis B, known as the anti-HBc test. A positive test shows that the virus has been present in the past and that vaccination is not necessary. currently got the virus in their blood by testing for a part of the virus itself, hepatitis B surface antigen, known as HBsAg. A positive test shows that the virus is present at the time of the test, and that the person is infectious. Both tests are desirable, but testing should not delay immunisation. Where possible, blood should be taken for testing at the same time as the first dose of vaccine is administered. Where blood testing is not possible, the full course of immunisation should be administered anyway. If a person’s blood test contains anti-HBc and shows them to have developed immunity through exposure to the virus the course of immunisation can be discontinued. The numbers of people who test positive for hepatitis B surface antigen will be low, but if a person’s blood test does contain HBsAg, (showing that they are currently infectious), they should be advised about how to prevent transmission to others and referred for medical assessment. Their sexual and household contacts should be strongly encouraged to complete a course of immunisation. A few people who have been infected with hepatitis B virus have persistent e-antigen (HbeAG) and are highly infectious ‘supercarriers’. Post-immunisation In the case of the accelerated schedule, a blood test should be taken 2 months after the third injection, as many people are likely to lose contact with services over a longer period. Booster doses of the vaccine can be given to people who do not develop significant immunity. Strategies for improving delivery of hepatitis B immunisation
These agencies could include:
Contract specifications can be used to ensure that services promote and provide hepatitis B immunisation in:
All general practitioners need to be aware that UK guidelines on the clinical management of drug users emphasise that drug users are as entitled to high-quality healthcare as any other group. GP’s should be encouraged to offer hepatitis B immunisation to their drug using patients and other members of high-risk groups routinely. Accident and emergency departments should be encouraged to routinely offer hepatitis B immunisation to those attending with drug related health problems such as overdose, abscesses and septicaemia. Ensure that policies and mechanisms are in place to guarantee that immunisations are offered to the sexual partners of those diagnosed with acute hepatitis B. Bibliography and further reading Best D, Noble A, Finch E et al. (1999) Accuracy of perceptions of hepatitis B and C status: cross sectional investigation of opiate addicts in treatment. British Medical Journal 1999, 319: 290-291. Borg L, Khuri E, Wells A et al. (1999) Methadone-maintained former heroin addicts including those who are anti-HIV-1 seropositive, comply with and respond to hepatitis B vaccination. Addiction 94(4):489-93. Department of Health, (1999) Health Service Circular 1999/036. Drug Misuse Special Allocation: 1999/2000. Funding and Guidance on the Modernisation Fund Element. Department of Health (1996) Immunisation against infectious diseases. 95-108. Heptonstall J (1999) Strategies to ensure delivery of hepatitis B vaccine to injecting drug users. Communicable Disease and Public Health Vol 3 Number 3 154 - 160.This paper was one of the principle sources used to write the strategiesfor promoting hepatitis B immunisation. Hughes N (October 1997) Hepatitis B vaccinationsÉ don’t care, won’t care. Mainliners Newsletter. 1-2. Kemp K (1997) The primary care unit. Report on activity and development within the Primary Care Unit from November 1994 to December 1997. London: Camden and Islington Community Health Service NHS Trust. Lamagni T L, Davison K L, Hope V D et al (1999) Poor hepatitis B vaccine coverage in injecting drug users: England 1995 and 1996. Communicable Disease and Public Health Vol 2 No. 3, 134-137. Morbidity and Mortality Weekly Report, 1996, No. 45, 1-35. Winstock A R, Sheridan J, Lovell S et al (2000). National Survey of Hepatitis Testing and vaccination Services provided by Drug Services in England and Wales. European Journal of Clinical and Microbiological Infectious Disease 19: 823-828.
We would like to thank all those who have assisted in producing this guide and the promoting hepatitis B immunisation campaign materials. Including: Jill Britton - Policy Officer, DrugScope. Stephen Green - Consultant in infectious diseases, Royal Hallamshire Hospital, Sheffield. Jaye Foster, the service users and the rest of the team - HOT, London. Nigel Hughes - Chief Executive, British Liver Trust. Julie Llewellyn RGN RMN - Hepatitis Nurse Specialist, Bristol Specialist Drug Service. Trudi Petersen RMN BSc PgDip - Hepatitis Nurse Specialist, Bristol Specialist Drug Service. Tom Waller - Specialist in substance misuse, Chair Action on Hepatitis C and past ACMD Member.
Published by Exchange Campaigns for DrugScope The authors are responsible for any errors or omissions.
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