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An accelerated hepatitis B vaccination schedule for young drug users

An accelerated hepatitis B vaccination schedule for young drug users Nich Rogers Youth Substance Abuse Service, Victoria Abstract Objective: To determine completion rates for an accelerated hepatitis B vaccine (HBV) program among a population of young drug users. Dan I. Lubman ORYGEN Research Centre, Department of Psychiatry, University of Melbourne, Victoria Design: Between January 2001 and May 2002, a three-dose course of HBV vaccine (0, 7 and 21 days) was offered free to all ne of the most prevalent and preventable harms associated with injecting drug use is infection with the hepatitis B virus (HBV). Rates of HBV infection are particularly high in this population, with prevalence f igures of between 38-89% reported across the United States, Europe and Australia.1-6 Infection rates are especially high among young people aged under 24 and account for the majority of notifications within Australia.6 While clinical guidelines emphasise drug users as ‘high risk’ for contracting HBV and propose that vaccination courses should be routinely offered within drug treatment settings,7,8 there appears to be low uptake of HBV vaccination among injecting drug users (IDUs).9,10 In addition, only a minority of drug users who begin vaccination ever complete the full course.10,11 This is not surprising given that it is traditionally offered as three injections over a six-month period (i.e. 0, one and six months). Recently however, new accelerated schedules have been developed for those travelling to HBV endemic regions at short notice without compromising seroprotection levels.12,13 Such results suggest that a shortened treatment course is likely to be advantageous among high-risk populations that are in contact with health services only for brief periods and rarely complete the traditional schedule. However, to date there has been little investigation of the acceptability of these accelerated regimes for young drug users. This project is the first to examine the feasibility of a free, 21-day, three-dose vaccination schedule for young drug users within a dedicated drug treatment service. drug users (aged 22 years or younger) accessing two outreach sites of a youthfocused support and drug treatment service in metropolitan Melbourne, Australia. Clients were offered vaccination in any safe environment of their choice. An audit was conducted on the health records of participating clients. Methods Between January 2001 and May 2002, a three-dose course of HBV vaccine (Engerix B, 20µg/1ml, GlaxoSmithKline) was offered to all young drug users (aged 22 years or younger) engaged by two outreach service sites of the Youth Substance Abuse Service (YSAS), a youth-focused support and drug treatment service. Some participants received case management, while others were opportunistically vaccinated via contacts made on the street. The vaccine was offered free of charge over a shortened schedule of 0, 7 and 21 days to all service users without a history of previous HBV vaccination or infection. Main outcome measures: Number of completed vaccinations; settings in which vaccinations were completed. Results: Ninety young people accepted vaccination, with 71% completing the full course. The majority preferred to receive vaccination at drug treatment outreach sites (53%). Conclusions: An accelerated vaccination schedule appears acceptable to young drug users, suggesting that vaccination programs can be successful when barriers to immunisation are appropriately identified and addressed. (Aust N Z J Public Health 2005; 29: 305-7) Recruitment Participants were identified and recruited via street-based contact or self-selection after viewing a promotional flyer. Participants were fully informed about the risks associated with HBV and the vaccine, and were required to give consent for the vaccination course. Parental consent was sought wherever possible. Participants were provided with information about the vaccination program and provided with an opportunity to discuss their preferred time and setting for vaccination. Two experienced Submitted: October 2004 Revision requested: April 2005 Accepted: April 2005 Correspondence to: Dr Dan Lubman, ORYGEN Research Centre, Locked Bag 10, Parkville, Victoria 3052. Fax: (03) 9342 2941; e-mail: dan.lubman@mh.org.au 2005 VOL. 29 NO. 4 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Rogers and Lubman Brief Report primary health nurses completed vaccinations in any safe environment chosen by the service user. Discussion Seventy-one per cent of participants completed the full threedose HBV vaccination schedule, an impressive result given the previously low completion rates among high-risk groups,10,11,14 including services specifically targeting adolescents and young people.15 While these other studies used a traditional six-month vaccination schedule, this project offered a three-dose course over 21 days, suggesting an accelerated course is a highly acceptable option for young drug users. While recent studies suggest that the majority of acute HBV infections occur in young people,6,15 the low rate of HBV vaccination among this population remains a major concern.15,16 For example, Kuo and colleagues16 reported that only 11% of their young drugusing cohort had been vaccinated against HBV In this latter study, . 84% had missed at least one opportunity for vaccination, despite continuing to engage in risky behaviours associated with HBV transmission.16 Furthermore, Wong and colleagues15 reported that while 90% of young people identified for HBV vaccination completed their first dose, only 10% completed the full course. These findings are particularly significant given that most new HBV infections occur soon after the initiation of injecting behaviour,4 with the majority of IDUs acquiring HBV within one year.3 It is therefore imperative that effective vaccination strategies targeted at young drug users are developed. Our results support suggestions that vaccination programs can be successful when barriers to immunisation are appropriately identified and addressed. In young drug-using populations, such barriers include access to health services,17 cost of vaccine,9 vaccination setting,18 and duration of the vaccination course.19 Thus, the removal of structural barriers in this project through proactive recruiting of at-risk youth (including non-IDUs), removing vaccination costs, shortening the time course of the vaccination schedule, and providing follow-up and reminder services, clearly assisted in the high level of completed vaccinations. In addition, the removal of attitudinal barriers, such Figure 1: HBV vaccination course completion rates (n=90) using an accelerated three-dose schedule (0, 7, and 21 days). Intervention process A three-dose vaccination course (0, 7 and 21 days) was provided over a three-week period. Reminders were provided directly via the nurse or via the participant’s youth outreach worker. Clientcentred prevention counselling was offered to all participants, as well as appropriate interventions to minimise any risks identified for contracting a blood-borne virus. The two YSAS Outreach sites chosen to participate in this project provided street-based outreach and case management services to about 500 clients over this period. Outreach staff provide education, information and referral advice, co-ordinated case management, and primary health services, including supported drug withdrawal via local residential and/or home-based services. Data collection Following completion of the project, an audit was conducted to assess the acceptability of the vaccination program and to quantify completion rates among participating young people. The health records of all participating clients were assessed and demographic, clinical and vaccination data were collected. Results Ninety young people aged between 14 and 22 years (average age 18.3) participated in the vaccination project. The sample included 48 females (53%) and 42 males (47%). Seventy per cent of participants were Anglo-Celtic and 15% were Indo-Chinese. Seventy per cent of participants were injecting drug users, the majority of whom stated heroin was their primary drug of choice. The opportunistic nature of this vaccination program meant information relating to the duration and/or severity of drug use was not available for the majority of participants. In addition, there were incomplete demographic, socio-behavioural and clinical data within the majority of accessed health records, which severely limited the research questions that could be addressed. Vaccination completion rates Seventy-one per cent of participants completed the full threedose course, with 11% receiving two injections and 18% attending for only their first vaccine (see Figure 1). Incomplete courses consisted of young people who were unable to be further contacted, or who repeatedly did not attend follow-up appointments. No participant directly refused any follow-up vaccination. Data were not kept on the number of initial vaccination refusals, and information relating to seroprotection rates was unavailable because of funding constraints. The preferred setting for receiving vaccination was YSAS Outreach sites (53%), drop-in counselling and information provision sites where youth outreach and nursing staff provide services to young people. Vaccinations within young people’s homes (24%) were also popular. The remainder preferred the YSAS residential withdrawal unit (12%), the day program (7%), or other settings (4%), such as in general practitioner clinics or community health centres. 80% 70% 60% 50% 40% 30% 20% 10% 0% 71% 18% 11% Completed full course Completed 2 of 3 injections Completed 1 of 3 injections AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2005 VOL. 29 NO. 4 Outbreaks An accelerated hepatitis B vaccination schedule as stigma and discrimination, by offering vaccinations within a non-clinical support service setting using experienced and specialist nursing staff, as well as providing preventive counselling and education, may also have contributed to the high vaccination rate. Similarly, the opportunity for participants to be involved in their own vaccination planning and delivery through choosing the setting may have led to fewer concerns about unfamiliar environments and potential stigma. This project successfully used active street outreach methods to recruit a youth population that is traditionally difficult to engage and has poor access to health programs and initiatives.20,21 Although we cannot comment on participation rates, the high rate of successful vaccinations remains clinically significant and compares favourably with the 47% completion rate achieved by Lum and colleagues,22 who utilised both street-based outreach and cash incentives. While the project produced high completion rates, it was not possible to determine whether those vaccinated achieved full seroprotection, although previous studies have demonstrated the efficacy of an accelerated vaccination course.23-25 For example, Marchou et al.23 reported seroprotection rates of 81.8% after one month and 96.4% after 12 months, while Bosnak et al.24 and Nothdurft et al.25 described rates of 95% and 92% at one year, respectively. Importantly, Bosnak and colleagues24 reported seroprotection rates of 65% at 28 days compared with 20% for the traditional six-month vaccination course, suggesting that the accelerated schedule provides enhanced early protection. This is particularly important given the ongoing high-risk behaviours demonstrated by young substance-using populations and the high rates of early infection among injecting initiates.3 However, despite these high levels of seroprotection, booster doses are recommended at 12 months to ensure long-lasting immunity,25 especially as seroconversion rates have been reported to be lower among drug-using populations.22,26 While limited by the retrospective nature of the audit and the lack of clinical data available, these preliminary results are of particular interest to those seeking to vaccinate groups at high risk of HBV infection. Our findings provide promising beginnings in the development of safe, acceptable, effective and achievable HBV vaccination programs for young drug users and other highrisk populations. Such results strongly support the ongoing provision of accelerated vaccination schedules through services that are in contact with and trusted by young drug users. By removing barriers and incorporating young people’s views into vaccination planning, it is likely that significant health benefits can be provided, as well as ongoing public health and economic savings for the wider community. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

An accelerated hepatitis B vaccination schedule for young drug users

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Publisher
Wiley
Copyright
Copyright © 2005 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.2005.tb00197.x
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Abstract

Nich Rogers Youth Substance Abuse Service, Victoria Abstract Objective: To determine completion rates for an accelerated hepatitis B vaccine (HBV) program among a population of young drug users. Dan I. Lubman ORYGEN Research Centre, Department of Psychiatry, University of Melbourne, Victoria Design: Between January 2001 and May 2002, a three-dose course of HBV vaccine (0, 7 and 21 days) was offered free to all ne of the most prevalent and preventable harms associated with injecting drug use is infection with the hepatitis B virus (HBV). Rates of HBV infection are particularly high in this population, with prevalence f igures of between 38-89% reported across the United States, Europe and Australia.1-6 Infection rates are especially high among young people aged under 24 and account for the majority of notifications within Australia.6 While clinical guidelines emphasise drug users as ‘high risk’ for contracting HBV and propose that vaccination courses should be routinely offered within drug treatment settings,7,8 there appears to be low uptake of HBV vaccination among injecting drug users (IDUs).9,10 In addition, only a minority of drug users who begin vaccination ever complete the full course.10,11 This is not surprising given that it is traditionally offered as three injections over a six-month period (i.e. 0, one and six months). Recently however, new accelerated schedules have been developed for those travelling to HBV endemic regions at short notice without compromising seroprotection levels.12,13 Such results suggest that a shortened treatment course is likely to be advantageous among high-risk populations that are in contact with health services only for brief periods and rarely complete the traditional schedule. However, to date there has been little investigation of the acceptability of these accelerated regimes for young drug users. This project is the first to examine the feasibility of a free, 21-day, three-dose vaccination schedule for young drug users within a dedicated drug treatment service. drug users (aged 22 years or younger) accessing two outreach sites of a youthfocused support and drug treatment service in metropolitan Melbourne, Australia. Clients were offered vaccination in any safe environment of their choice. An audit was conducted on the health records of participating clients. Methods Between January 2001 and May 2002, a three-dose course of HBV vaccine (Engerix B, 20µg/1ml, GlaxoSmithKline) was offered to all young drug users (aged 22 years or younger) engaged by two outreach service sites of the Youth Substance Abuse Service (YSAS), a youth-focused support and drug treatment service. Some participants received case management, while others were opportunistically vaccinated via contacts made on the street. The vaccine was offered free of charge over a shortened schedule of 0, 7 and 21 days to all service users without a history of previous HBV vaccination or infection. Main outcome measures: Number of completed vaccinations; settings in which vaccinations were completed. Results: Ninety young people accepted vaccination, with 71% completing the full course. The majority preferred to receive vaccination at drug treatment outreach sites (53%). Conclusions: An accelerated vaccination schedule appears acceptable to young drug users, suggesting that vaccination programs can be successful when barriers to immunisation are appropriately identified and addressed. (Aust N Z J Public Health 2005; 29: 305-7) Recruitment Participants were identified and recruited via street-based contact or self-selection after viewing a promotional flyer. Participants were fully informed about the risks associated with HBV and the vaccine, and were required to give consent for the vaccination course. Parental consent was sought wherever possible. Participants were provided with information about the vaccination program and provided with an opportunity to discuss their preferred time and setting for vaccination. Two experienced Submitted: October 2004 Revision requested: April 2005 Accepted: April 2005 Correspondence to: Dr Dan Lubman, ORYGEN Research Centre, Locked Bag 10, Parkville, Victoria 3052. Fax: (03) 9342 2941; e-mail: dan.lubman@mh.org.au 2005 VOL. 29 NO. 4 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Rogers and Lubman Brief Report primary health nurses completed vaccinations in any safe environment chosen by the service user. Discussion Seventy-one per cent of participants completed the full threedose HBV vaccination schedule, an impressive result given the previously low completion rates among high-risk groups,10,11,14 including services specifically targeting adolescents and young people.15 While these other studies used a traditional six-month vaccination schedule, this project offered a three-dose course over 21 days, suggesting an accelerated course is a highly acceptable option for young drug users. While recent studies suggest that the majority of acute HBV infections occur in young people,6,15 the low rate of HBV vaccination among this population remains a major concern.15,16 For example, Kuo and colleagues16 reported that only 11% of their young drugusing cohort had been vaccinated against HBV In this latter study, . 84% had missed at least one opportunity for vaccination, despite continuing to engage in risky behaviours associated with HBV transmission.16 Furthermore, Wong and colleagues15 reported that while 90% of young people identified for HBV vaccination completed their first dose, only 10% completed the full course. These findings are particularly significant given that most new HBV infections occur soon after the initiation of injecting behaviour,4 with the majority of IDUs acquiring HBV within one year.3 It is therefore imperative that effective vaccination strategies targeted at young drug users are developed. Our results support suggestions that vaccination programs can be successful when barriers to immunisation are appropriately identified and addressed. In young drug-using populations, such barriers include access to health services,17 cost of vaccine,9 vaccination setting,18 and duration of the vaccination course.19 Thus, the removal of structural barriers in this project through proactive recruiting of at-risk youth (including non-IDUs), removing vaccination costs, shortening the time course of the vaccination schedule, and providing follow-up and reminder services, clearly assisted in the high level of completed vaccinations. In addition, the removal of attitudinal barriers, such Figure 1: HBV vaccination course completion rates (n=90) using an accelerated three-dose schedule (0, 7, and 21 days). Intervention process A three-dose vaccination course (0, 7 and 21 days) was provided over a three-week period. Reminders were provided directly via the nurse or via the participant’s youth outreach worker. Clientcentred prevention counselling was offered to all participants, as well as appropriate interventions to minimise any risks identified for contracting a blood-borne virus. The two YSAS Outreach sites chosen to participate in this project provided street-based outreach and case management services to about 500 clients over this period. Outreach staff provide education, information and referral advice, co-ordinated case management, and primary health services, including supported drug withdrawal via local residential and/or home-based services. Data collection Following completion of the project, an audit was conducted to assess the acceptability of the vaccination program and to quantify completion rates among participating young people. The health records of all participating clients were assessed and demographic, clinical and vaccination data were collected. Results Ninety young people aged between 14 and 22 years (average age 18.3) participated in the vaccination project. The sample included 48 females (53%) and 42 males (47%). Seventy per cent of participants were Anglo-Celtic and 15% were Indo-Chinese. Seventy per cent of participants were injecting drug users, the majority of whom stated heroin was their primary drug of choice. The opportunistic nature of this vaccination program meant information relating to the duration and/or severity of drug use was not available for the majority of participants. In addition, there were incomplete demographic, socio-behavioural and clinical data within the majority of accessed health records, which severely limited the research questions that could be addressed. Vaccination completion rates Seventy-one per cent of participants completed the full threedose course, with 11% receiving two injections and 18% attending for only their first vaccine (see Figure 1). Incomplete courses consisted of young people who were unable to be further contacted, or who repeatedly did not attend follow-up appointments. No participant directly refused any follow-up vaccination. Data were not kept on the number of initial vaccination refusals, and information relating to seroprotection rates was unavailable because of funding constraints. The preferred setting for receiving vaccination was YSAS Outreach sites (53%), drop-in counselling and information provision sites where youth outreach and nursing staff provide services to young people. Vaccinations within young people’s homes (24%) were also popular. The remainder preferred the YSAS residential withdrawal unit (12%), the day program (7%), or other settings (4%), such as in general practitioner clinics or community health centres. 80% 70% 60% 50% 40% 30% 20% 10% 0% 71% 18% 11% Completed full course Completed 2 of 3 injections Completed 1 of 3 injections AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2005 VOL. 29 NO. 4 Outbreaks An accelerated hepatitis B vaccination schedule as stigma and discrimination, by offering vaccinations within a non-clinical support service setting using experienced and specialist nursing staff, as well as providing preventive counselling and education, may also have contributed to the high vaccination rate. Similarly, the opportunity for participants to be involved in their own vaccination planning and delivery through choosing the setting may have led to fewer concerns about unfamiliar environments and potential stigma. This project successfully used active street outreach methods to recruit a youth population that is traditionally difficult to engage and has poor access to health programs and initiatives.20,21 Although we cannot comment on participation rates, the high rate of successful vaccinations remains clinically significant and compares favourably with the 47% completion rate achieved by Lum and colleagues,22 who utilised both street-based outreach and cash incentives. While the project produced high completion rates, it was not possible to determine whether those vaccinated achieved full seroprotection, although previous studies have demonstrated the efficacy of an accelerated vaccination course.23-25 For example, Marchou et al.23 reported seroprotection rates of 81.8% after one month and 96.4% after 12 months, while Bosnak et al.24 and Nothdurft et al.25 described rates of 95% and 92% at one year, respectively. Importantly, Bosnak and colleagues24 reported seroprotection rates of 65% at 28 days compared with 20% for the traditional six-month vaccination course, suggesting that the accelerated schedule provides enhanced early protection. This is particularly important given the ongoing high-risk behaviours demonstrated by young substance-using populations and the high rates of early infection among injecting initiates.3 However, despite these high levels of seroprotection, booster doses are recommended at 12 months to ensure long-lasting immunity,25 especially as seroconversion rates have been reported to be lower among drug-using populations.22,26 While limited by the retrospective nature of the audit and the lack of clinical data available, these preliminary results are of particular interest to those seeking to vaccinate groups at high risk of HBV infection. Our findings provide promising beginnings in the development of safe, acceptable, effective and achievable HBV vaccination programs for young drug users and other highrisk populations. Such results strongly support the ongoing provision of accelerated vaccination schedules through services that are in contact with and trusted by young drug users. By removing barriers and incorporating young people’s views into vaccination planning, it is likely that significant health benefits can be provided, as well as ongoing public health and economic savings for the wider community.

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Aug 1, 2005

There are no references for this article.