Original Research

Accelerated Hepatitis A and B Immunization in a Substance Abuse Treatment Program

Fed Pract. 2015 August;32(8):38-44

References

1. Nyamathi A, Liu Y, Marfisee M, et al. Effects of a nurse-managed program on hepatitis A and B vaccine completion among homeless adults. Nurs Res. 2009;58(1):13-22.

2. Center for Disease Control and Prevention (CDC). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR Morb Mortal Wkly Rep. 2006;55(RR16):1-25.

3. Advisory Committee on Immunization Practices (ACIP), Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2006;55(RR07):1-23.

4. Weltman MD, Brotodihardjo A, Crewe EB, et al. Coinfection with hepatitis B and C or B, C and delta viruses results in severe chronic liver disease and responds poorly to interferon-alpha treatment. J Viral Hepat. 1995;2(1):39-45.

5. Groessl EJ, Weingart KR, Kaplan RM, et al. Living with hepatitis C: qualitative interviews with hepatitis C-infected veterans. J Gen Intern Med. 2008;23(12):1959-1965.

6. Dominitz JA, Boyko EJ, Koepsell TD, et al. Elevated prevalence of hepatitis C infection in users of United States veterans medical centers. Hepatology. 2005;41(1):88-96.

7. Himeloch S, McCarthy JF, Ganoczy D, et al. Understanding associations between serious mental illness and hepatitis C virus among veterans: a national multivariate analysis. Psychosomatics. 2009;50(1):30-37.

8. Hagedorn H, Dieperink E, Dingmann D, et al. Integrating hepatitis prevention services into a substance use disorder clinic. J Subst Abuse Treat. 2007;32(4):391-398.

9. Ramasamy P, Lintzeris N, Sutton Y, Taylor H, Day CA, Haber PS. The outcome of a rapid hepatitis B vaccination programme in a methadone treatment clinic. Addiction. 2010;105(2):329-334.

10. Bini EJ, Kritz S, Brown LS Jr, et al. Hepatitis B virus and hepatitis C virus services offered by substance abuse treatment programs in the United States. J Subst Abuse Treat. 2012;42(4):438-445.

11. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 1998;47(RR-19):1-39.

12. Francis E, Gonzales-Nolas CL, Markowitz J, Phillips S. Integration of preventive health screening into mental health clinics. Fed Pract. 2008;25(2):39-50.

13. Vreeland B. Bridging the gap between mental and physical health: a multidisciplinary approach. J Clin Psychiatry. 2007;68(suppl 4):26-33.

14. Brim N, Zaller N, Taylor LE, Feller E. Twinrix vaccination schedules among injecting drug users. Expert Opin Biol Ther. 2007;7(3):379-389.

15. Zuckerman J. The place of accelerated schedules for hepatitis A and B vaccinations. Drugs. 2003;63(17):1779-1784.

16. Connor BA, Blatter MM, Beran J, Zou B, Trofa AF. Rapid and sustained immune response against hepatitis A and B achieved with combined vaccine using an accelerated administration schedule. J Travel Med. 2007;14(1):9-15.

17. Nothdurft HD, Dietrich M, Zuckerman JN, et al. A new accelerated vaccination schedule for rapid protection against hepatitis A and B. Vaccine. 2002;20(7-8):1157-1162.

18. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.

19. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict. 1991;86(9):1119-1127.

20. McLellan AT, Kushner H, Metzger D, et al. The Fifth Edition of the Addiction Severity Index. J Subst Abuse Treat. 1992;9(3):199-213.

21. Batki SL, Nathan KI. HIV/AIDS and Hepatitis C. In: Galanter M, Kleber HD, Brady KT, eds. The American Psychiatric Publishing Textbook of Substance Abuse Treatment. 5th ed. Arlington, VA: American Psychiatric Publishing; 2015.

22. Gelberg L, Robertson MJ, Leake B, et al. Hepatitis B among homeless and other impoverished US military veterans in residential care in Los Angeles. Public Health. 2001;115(4):286-291.

23. Felsen UR, Fishbein DA, Litwin AH. Low rates of hepatitis A and B vaccination in patients with chronic hepatitis C at an urban methadone maintenance program. J Addict Dis. 2010;29(4):461-465.

24. Brewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein ND. Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychol. 2007;26(2):136-145.

25. Soto-Salgado M, Suárez E, Ortiz AP, et al. Knowledge of viral hepatitis among Puerto Rican adults: implications for prevention. J Community Health. 2011;36(4):565-573.

26. Cox AD, Cox D, Cyrier R, Graham-Dotson Y, Zimet GD. Can self-prediction overcome barriers to hepatitis B vaccination? A randomized controlled trial. Health Psychol. 2012;31(1):97-105.

27. Stitzer ML, Polk T, Bowles S, Kosten T. Drug users’ adherence to a 6-month vaccination protocol: effects of motivational incentives. Drug Alcohol Depend. 2010;107(1):76-79.

Nearly half (48%) of all the eligible patients admitted to the program began the accelerated immunization schedule for hepatitis A and B. Of those, 88% completed the first 3 injections in the series. Among the patients who received the first 3 injections, 48% received the 1-year booster injection—a 20% completion rate for the vaccination-eligible sample overall (Table 3).

Of the 74 patients who did not complete their vaccinations once initiating the accelerated schedule, the most common reason identified was that the patient moved away (37), or no reason could be identified (33). It was uncommon for a patient not to complete the vaccination schedule because of terminating treatment prematurely (4).

Compared with the vaccine-eligible patients without hepatitis C (207), patients with hepatitis C were less likely to receive any vaccination injections (Table 3). Specifically, 51% of the vaccination-eligible patients who did not have hepatitis C began the vaccination regimen. However, only 22 patients with hepatitis C, or
35% of all vaccination-eligible patients with hepatitis C, began the vaccination regimen. Patients with hepatitis C were also less likely than those without hepatitis C to complete the first 3 injections of the vaccination series once they had initiated it (77%, vs 90%, respectively). This difference continued to be apparent at the time of the 12-month booster injection. Only 35% of vaccine-eligible individuals with hepatitis C received the 12-month booster injection, whereas 51% of vaccination-eligible individuals without hepatitis C received the 12-month booster injection. As with the sample overall, the most common reason patients with hepatitis C did not complete the vaccination regimen was because they moved away (9), followed by no identified reason (5), and premature termination of treatment (2).

Discussion

Individuals abusing alcohol and drugs have an increased vulnerability for infectious diseases, and homeless veterans with substance use disorders may be at a particularly heightened risk.^21,22 This study describes a sample of veterans, many were homeless and most were dually diagnosed, in an intensive outpatient SATP that offered an accelerated dosing regimen for hepatitis A and B vaccination. Almost half (48%) of the vaccination-eligible patients began the accelerated regimen for hepatitis A/B vaccination. Moreover, 88% of those who started the vaccination regimen received the first 3 injections of the series, thus possibly conferring substantial immunity to hepatitis A and B and demonstrating the feasibility of an accelerated vaccination schedule in an intensive outpatient SATP.

It is especially important to demonstrate the successful integration of a hepatitis screening and immunization program within a SATP, given that many such programs do not offer screening or immunization for hepatitis, even though substance abusers are disproportionately affected by the disease and contribute greatly to the ongoing hepatitis epidemic.^10,11 This study’s results were in line with another study of rapid vaccination for hepatitis B in IV drug users being treated in a methadone clinic, where 83% of the vaccination initiators completed the first 3 injections of the series.⁹

Unvaccinated Patients

The treatment team in the current study seemed to be less effective at reaching the subset of vaccination-eligible veterans with hepatitis C (almost one-quarter of the sample) in order to administer the accelerated vaccination schedule, as indicated by the lower rate of vaccination initiation as well as a lower rate of completion of the vaccination series among those patients. This replicates a finding from another study that also indicated a low rate of hepatitis A and B vaccination among patients with hepatitis C.²³ Only 35% of the vaccination-eligible patients with hepatitis C in the current study initiated the vaccination series, compared with 51% of the patients without hepatitis C. However, the rate of completion of the first 3 injections of the series in the hepatitis C group was respectably high (77%), especially given the high relapse rate and psychosocial instability of individuals with addictive disorders. Initiation seems to be a bigger obstacle than completion of at least the first 3 injections of the vaccination series in both patients with and without hepatitis C.

The study investigators did not formally assess the reasons that more than half the patients in the study did not begin the vaccination series, but anecdotal evidence from the nurses indicated that many patients were afraid of needles. In addition, other patients felt that they simply did not need the vaccination. Some also insisted that they had already had the vaccination despite a blood test showing no evidence for either hepatitis A or B immunization.

Although the nursing team provided group and individual risk-based education as well as information about the effects of continued substance abuse on hepatitis C, it is possible that patients still underestimated their own risk of hepatitis infection and its consequences, or perhaps the information was simply not retained.²⁴