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Contents Promoting hepatitis B vaccination Hepatitis B infection is preventable with a simple course of three vaccinations. Despite considerable improvements in the level of hepatitis B vaccinations amongst injecting drug users, much of this improvement has been in prison settings. Many more injectors could be offered vaccination through drug treatment services or needle exchanges. This guide and the supporting materials are designed to help promotion of the wide availability of vaccination. This briefing forms a part of ‘Harm Reduction Works’, a National Treatment Agency and Department of Health initiative. It is intended to give professionals working with drug users, tools to implement essential harm reduction interventions among injecting drug users. If the strategy of vaccinating injecting drug users, and others at risk from contact with injecting drug users, is to be as effective as possible, services have to find effective ways of ensuring that:
This guide gives information on:
Hepatitis B The hepatitis B virus:
Transmission of hepatitis B infection can occur through:
Hepatitis B can cause serious liver disease. For people who are infected with both hepatitis B and hepatitis C the risk of serious liver disease is MUCH higher. Shooting Up, The Health Protection Agency report for 2008, shows that about 1 in 6 injecting drug users have had a hepatitis B infection. This means that through immunisation hepatitis B can be prevented in the majority of the remaining 85% of injecting drug users. Hepatitis B vaccination However, there are wide regional variations in the levels of uptake of hepatitis B vaccination. In England, the 2006/07 Healthcare Commission NTA joint improvement review on harm reduction indicated only 4% of areas as either excellent or good in relation to hepatitis B vaccination. There are clear opportunities to build on the improvements to date. The Health Protection Agency has also expressed concern that most dedicated needle exchanges, which may see injectors sooner than the other settings and could therefore provide protection earlier, do not provide onsite vaccinations. A 2003/4 survey of injectors who had been vaccinated and looking at where the vaccination took place found:
Whilst not all needle exchanges will be able to provide vaccination to injectors and their vulnerable family and friends, it appears that many that could be providing vaccination are not doing so or are not doing it as effectively as they could. In 2006, the National Treatment Agency for Substance Misuse (NTA) second Annual Service User Satisfaction Survey reported that 1 in 5 injectors requested hepatitis B vaccination but did not receive it. Hepatitis B vaccination can be monitored by services and commissioners. This can be used as a basis for achieving significant improvement. Vaccination – practicalities The target groups for vaccination via drug treatment services and needle exchanges are:
Consideration should be given to use of the most accelerated option of 0, 7 and 21 days because it has most chance of being completed by the target group. However, this accelerated schedule is slightly less likely to be effective than other more protracted schedules and for this reason a booster should be offered at 12 months when it is used. In other cases, for example in the light of hepatitis A outbreaks, the combined hepatitis A and B vaccine may be used preferentially. Although it is good practice to offer blood testing in needle exchanges for all three blood borne viruses (HBV, HCV and HIV), blood testing is not a necessity prior to vaccination since the vaccine will do no harm to those who have been previously infected with hepatitis B. An example service protocol for hepatitis B vaccination is available here An example of a patient group direction for providing hepatitis B vaccination is available here Strategies for improving vaccine uptake and course completion Drug partnerships such as Drug and Alcohol Action Teams can ensure:
Target agencies for promotional media and dissemination of information could include:
Vaccine safety The risks of hepatitis B infection, especially to those who already have hepatitis C, mean that such small risks associated with vaccination are far outweighed by the benefits - which can be life-saving. Hepatitis A vaccine Hepatitis A vaccine can be given as a 2 dose schedule over 6 to 12 months when using the single component vaccine (usually the preferred option), or as a 3 dose schedule over 3 weeks to 6 months when using the combined hepatitis A/B vaccine. As with hepatitis B, there is no need to blood test for viral status prior to vaccination. Bibliography and further reading Baral S. Sherman S. Millson P. et al Vaccine immunogenicity in injecting drug users: a systematic review The Lancet Volume 7, Issue 10, October 2007, Pages 667-674 National Treatment Agency for Substance Misuse, Harm Reduction Strategy – Guidance to support adult drug treatment planning 2008/09
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