Poor criterion validity of self-reported hepatitis B infection and vaccination status among injecting drug users: A review

Vaccination coverage among people who inject drugs: A systematic review

BACKGROUND

People who inject drugs may be at excess risk of acquiring vaccine-preventable diseases and negative associated health outcomes, but experience barriers to vaccination. We aimed to determine vaccination coverage among people who inject drugs globally.

METHODOLOGY

We conducted systematic searches of the peer-reviewed and grey literature, date limited from January 2008 to August 2023, focusing on diseases for which people who inject drugs are at elevated risk for and for which an adult vaccination dose is recommended (COVID-19, hepatitis A, hepatitis B, human papillomavirus, influenza, pneumococcal disease, tetanus). To summarise available data, we conducted a narrative synthesis.

RESULTS

We included 78 studies/reports comprising 117 estimates of vaccination coverage across 36 countries. Most estimates were obtained from high income countries (80%, n=94). We located estimates for hepatitis B vaccination in 33 countries, which included 18 countries with data on serological evidence of vaccine-derived hepatitis B immunity (range: 6-53%) and 22 countries with self-report data for vaccine uptake (<1-96%). Data for other vaccines were scarcer: reported hepatitis A vaccination coverage ranged 3-89% (five countries), COVID-19 ranged 4-84% (five countries), while we located estimates from fewer than five countries for influenza, tetanus, pneumococcal disease, and human papillomavirus.

CONCLUSION

Estimates were sparse but where available indicative of suboptimal vaccination coverage among people who inject drugs. Improving the consistency, timeliness, and geographic coverage of vaccine uptake data among this population is essential to inform efforts to increase uptake.

Reliability of prisoners' survey responses: comparison of self-reported health and biomedical data from an australian prisoner cohort

OBJECTIVE

Prisoner health surveys primarily rely on self-report data. However, it is unclear whether prisoners are reliable health survey respondents. This paper aimed to determine the level of agreement between self-report and biomedical tests for a number of chronic health conditions.

METHOD

This study was a secondary analysis of existing data from three waves (1996, 2001, 2009) of the New South Wales (NSW) Inmate Health Survey. The health surveys were cross-sectional in nature and included a stratified random sample of men (n=2,114) from all NSW prisons. Self-reported histories of hepatitis, sexually transmissible infections, and diabetes were compared to objective biomedical measures of these conditions.

RESULTS

Overall, the sensitivity (i.e., the respondents who self-reported having the condition also had markers indicative of the condition using biomedical tests) was high for hepatitis C (96%) and hepatitis B (83%), but low for all other assessed conditions (ranging from 9.1% for syphilis using RPR to 64% for diabetes). However, Kappa scores indicated substantial agreement only for hepatitis C. That is, there were false positives and false negatives which occurred outside of chance leading to poor agreement for all other assessed conditions.

CONCLUSIONS

Prisoners may have been exposed to serious health conditions while failing to report a history of infection. It may be possible that prisoners do not get tested given the asymptomatic presentation of some conditions, were unaware of their health status, have limited health-service usage preventing the opportunity for detection, or are subject to forgetting or misunderstanding prior test results. These findings demonstrate the importance of the custodial environment in screening for health conditions and referral for treatment should this be needed. Testing on entry, periodically during incarceration, and prior to release is recommended.

Hepatitis B vaccination coverage in Germany: systematic review

BACKGROUND

Despite being considered as a low prevalence country for hepatitis B (HBV), some populations in Germany are at higher risk of infection. In the context of the World Health Organization's (WHO) viral hepatitis elimination goals, a valid epidemiological data base is needed to plan and monitor the national response. Prevention strategies include general and targeted HBV vaccination programmes.

OBJECTIVE

The aim of this work was to estimate the HBV vaccination coverage (VC) in the general population (GP) and different population groups in Germany from available evidence and to identify current evidence gaps for future research.

METHODS

We conducted a systematic review on HBV VC in the general population and populations at high risk of HBV exposure or severe infection in Germany. We included eligible publications (01/01/2017 to 06/06/2020) from databases Embase, Pubmed and Livivo, from a previous scoping review (including data published 01/01/2005-17/03/2017), from the national surveillance system and screened the reference lists of all publications at full text level. Risk of bias was assessed using the Hoy et al. tool.

RESULTS

We included 68 publications of 67 studies and assigned them to one or more suitable population groups. Twenty-one studies contained data among children/adolescents and three among adults from the GP (VC 65.8-90.5% and 22.9-52.1%, respectively), one among travelers (VC 89.0%), 13 among immunocompromised populations (VC 7.8-89.0%), 16 among populations with occupational risk and 16 with non-occupational risk of HBV exposure (VC 63.6-96.5% and 4.4-84.5%, respectively).

CONCLUSION

Comprehensive evidence at low risk of bias was identified for children/adolescents. However, 25 years after including HBV in the national immunisation schedule, VC in Germany is still below the 95%-goal defined by WHO. For people at occupational risk of HBV exposure, VC was mostly reported to be over the WHO goal of 80%, but quality of evidence was heterogenous and should be improved. For people at non-occupational risk of HBV exposure, evidence was sparse and of low quality. The low VC highlights the need for future research to plan vaccination programmes targeting these populations.

Hepatotropic viruses (hepatitis A, B, C, D and E) in a rural Brazilian population: prevalence, genotypes, risk factors and vaccination

BACKGROUND

People living in settlement projects represent an emergent rural population in Brazil. Data on their health is scarce and there are no data on viral hepatitis in this population. This study investigated the epidemiology of viral hepatitis A-E in residents of settlement projects in central Brazil.

METHODS

During 2011 and 2012, 923 people living in rural settlements in central Brazil were interviewed and tested to estimate the prevalence of exposure to viral hepatitis A-E, to identify the circulating hepatitis B virus (HBV)/hepatitis C virus (HCV) genotypes and risk factors for HBV exposure and to evaluate adherence to the hepatitis B vaccination series.

RESULTS

Overall, 85.9, 3.9, 0.4 and 17.3% of individuals showed evidence of exposure to hepatitis A virus (HAV), hepatitis E virus, HCV and HBV, respectively. Among HBV-DNA positive samples (n=8), subgenotypes A1 (n=3) and A2 (n=1) and genotype D/subgenotype D3 (n=4) were identified. Hepatitis D virus superinfection was detected in 0/16 HBsAg-positive participants. A total of 229 individuals showed serological evidence of HBV vaccination. In total, 442 settlers were eligible for vaccination, but only 150 individuals completed the vaccine series. All anti-HCV-positive samples (n=4) were also HCV-RNA positive and identified as subtype 1a.

CONCLUSIONS

The intermediate endemicity of HAV, the higher prevalence of HBV exposure compared with urban areas and the low compliance with HBV vaccination requires preventive measures focused on rural populations, emphasizing the need for HAV and HBV vaccination.

Susceptibility to Hepatitis A and B Virus Among Clients at a Syringe Services Program in Philadelphia, 2018

OBJECTIVES

Although many people who use drugs meet criteria for vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV), estimates of susceptibility (ie, lack of immunity) are not well established. This study sought to identify the prevalence of and characteristics associated with HAV and HBV susceptibility among people who use drugs attending an urban syringe services program.

METHODS

We initiated this seroprevalence study in 2018 among 438 clients of a syringe services program who met study criteria, including provision of a blood specimen and a self-reported history of drug use. We assessed HAV and HBV susceptibility and infection via serological testing. We examined associations between participant characteristics and serology status by using descriptive statistics and multivariable logistic regression models.

RESULTS

Of the initial 438 clients identified, 353 (80.6%) met study criteria. Of 352 participants with conclusive HAV test results, 48.6% (n = 171) were HAV susceptible; of 337 participants with conclusive HBV test results, 32.6% (n = 110) were HBV susceptible, 24.3% (n = 82) showed evidence of past or present HBV infection, and 43.0% (n = 145) had vaccine-derived immunity. Compared with participants born before 1970, participants born during 1980-1989 had 5.90 (95% CI, 2.42-14.40) times the odds of HAV susceptibility and 0.18 (95% CI, 0.06-0.53) times the odds of HBV susceptibility, and participants born during 1990-1999 had 6.31 (95% CI, 2.34-17.00) times the odds of HAV susceptibility. Decreased odds of HAV susceptibility were associated with homelessness (adjusted odds ratio = 0.48; 95% CI, 0.28-0.82).

CONCLUSION

Despite applicable HAV and HBV vaccination recommendations, substantial gaps exist in HAV and HBV susceptibility among a population of people who use drugs. These findings highlight the need for increased HAV and HBV vaccination efforts among people who use drugs.

Factors associated with self-reported hepatitis B virus vaccination status among men who have sex with men in the Netherlands

Background Reducing the number of new acute hepatitis B virus (HBV) infections to zero by 2022 is an important goal in the Netherlands. Free HBV vaccination is available for population groups at higher risk of infection, including men who have sex with men (MSM). Identifying correlates of HBV vaccination among MSM can guide the development of health promotion interventions to increase coverage of HBV vaccination.

METHODS

We assessed factors associated with the HBV vaccination status of 4270 MSM in the Netherlands. Data were collected through the 2018 online Men & Sexuality survey.

RESULTS

Multinomial regression analysis showed that lower education level, having never tested for HIV, not recently diagnosed with a sexually transmissible infection, recently having had sex abroad and unknown HBV testing status were associated with higher odds of being unvaccinated as opposed to fully vaccinated. Living in Amsterdam and testing HBV negative were associated with lower odds of being unvaccinated as opposed to fully vaccinated. Age (25-39 years vs younger ages), living in Amsterdam and using pre-exposure prophylaxis decreased the odds to be partly vaccinated as opposed to fully vaccinated; having a migration background increased these odds.

CONCLUSIONS

HBV vaccination rates among MSM will not reduce HBV transmission to zero. HBV promotion should focus on MSM outside of Amsterdam who are likely less connected with sexual health services and may be at lower (perceived) risk. The factors identified related to HBV vaccination status provide guidance for health promotion interventions to increase uptake and vaccination completion among MSM.

Self-reported patient history to assess hepatitis B virus serological status during a large screening campaign

When assessing hepatitis B virus (HBV) status in clinical settings, it is unclear whether self-reports on vaccination history and previous HBV-test results have any diagnostic capacity. Of 3997 participants in a multi-centre HBV-screening study in Paris, France, 1090 were asked questions on their last HBV-test result and vaccination history. Discordance between self-reported history compared with infection status (determined by serology) was calculated for participants claiming ‘negative’, ‘effective vaccine’, ‘past infection’, or ‘chronic infection’ HBV-status. Serological testing revealed that 320 (29.4%) were non-immunised, 576 (52.8%) were vaccinated, 173 (15.9%) had resolved the infection and 21 (1.9%) were hepatitis B surface antigen positive. In total 208/426 (48.8%) participants with a self-reported history of ‘negative’ infection had a discordant serological result, in whom 128 (61.5%) were vaccinated and 74 (35.6%) had resolved infections. A total of 153/599 (25.5%) participants self-reporting ‘effective vaccine’ had a discordant serological result, in whom 100 (65.4%) were non-immunised and 50 (32.7%) were resolved infections. Discordance for declaring ‘past’ or ‘chronic infection’ occurred in 9/55 (16.4%) and 3/10 (30.0%) individuals, respectively. In conclusion, self-reported HBV-status based on participant history is partially inadequate for determining serological HBV-status, especially between negative/vaccinated individuals. More adapted patient education about HBV-status might be helpful for certain key populations.

Outcome of a hepatitis B vaccination program for clients of a drug consumption facility

BACKGROUND

Intravenous drug users (IDUs) are a risk group for hepatitis B. In Germany, the hepatitis B virus (HBV) vaccination rates in IDUs are low.

OBJECTIVES

In this study the implementation and success of HBV vaccination in a drug consumption facility (DCF) was evaluated.

STUDY DESIGN

Clients attending a DCF were asked regarding their HBV status. In case of no known HBV infection and no previous vaccination, clients interested in HBV vaccination were offered a HBV blood testing. HBV vaccination was administered to susceptible clients in months 0, 1, 6. Booster vaccinations were offered to clients without seroconversion (anti-HBs < 100 U/l).

RESULTS

193 out of 364 clients reported on a known HBV infection or immunity after vaccination. 95 (55.6%) out of 171 eligible clients underwent a HBV serology. According to HBV serology 31 (32.6%) out of 95 clients were not susceptible for vaccination (mainly due to an unknown HBV infection). 47 (73.4%) out of 64 clients susceptible were administered 3 vaccinations. 10 clients received at least one further vaccination. For those showing up for testing (36 out of 47 clients) the seroconversion rate was 69.4% (> 100 IU/l) and 83.3% (> 10 IU/l), respectively.

DISCUSSION

Only a minority of clients of a DCF was susceptible for HBV vaccination. 47 out of 64 (73.4%) susceptible clients underwent at least three administrations of the vaccine, mostly resulting in seroconversion. Even in IDUs attending a DCF, a clientele with unstable social and health conditions, HBV vaccination can be carried out successfully.

A large proportion of people who inject drugs are susceptible to hepatitis B: Results from a bio-behavioural study in eight German cities

BACKGROUND

People who inject drugs (PWID) are at high risk of hepatitis B virus (HBV) infection by sharing needles and drug use paraphernalia. In Germany, no routine surveillance of HBV prevalence and vaccination coverage among PWID exists.

METHODS

Socio-demographic and behavioural data were collected between 2011 and 2014 through face-to-face interviews, during a bio-behavioural survey of PWID recruited in eight German cities. Dried blood spots (DBS) prepared with capillary blood were tested for HBV markers. Factors associated with past/current HBV infection and vaccination status were analysed by univariable and multivariable analysis using logistic regression. The validity of self-reported HBV infection and vaccination status was analysed by comparison to the laboratory results.

RESULTS

Among 2077 participants, the prevalence of current HBV infection was 1.1%, of past HBV infection was 24%, and of vaccine-induced HBV antibodies was 32%. No detectable HBV antibodies were found in 43%. HBV infection status was significantly associated with study city, age, years of injecting, use of stimulants, migration status, and homelessness; HBV vaccination status was significantly associated with study city, age, and level of education. Correct infection status was reported by 71% and correct vaccination status by 45%.

CONCLUSIONS

HBV seroprevalence among PWID was about five times higher than in the general population in Germany, confirming PWID as an important risk group. Targeted information campaigns on HBV and HBV prevention for PWID and professionals in contact with PWID need to be intensified. Routinely offered HBV vaccination during imprisonment and opioid substitution therapy would likely improve vaccination rates among PWID.

Prevalence, risk factors and hepatitis B immunization: helping fill the gap on hepatitis B epidemiology among homeless people, Goiânia, Central Brazil

Data are limited in Brazil on hepatitis B infection among homeless individuals, a marginalized population with high risk of sexually transmissible infections (STI), including hepatitis B. The aim of this study was to investigate hepatitis B epidemiology in homeless persons lodged in a public shelter in Goiânia, Central Brazil. From August 2014 to June 2015, 353 individuals were interviewed and tested for markers of HBV infection. Overall HBV prevalence was 21.8% (95%CI: 17,82-26,41), and 19,5% (95%CI: 15,75-24,0) showed a serological profile of previous HBV vaccination. Older individuals (> 50 years), blacks, and homosexuals or bisexuals showed increased exposure to HBV. The low frequency of individuals immunized against HBV, high social vulnerability, and risk behaviors emphasize the need for health services administrators to provide more opportunities for HBV vaccination in this target population.

Use of multiple data sources to estimate hepatitis C seroprevalence among prisoners: A retrospective cohort study

Hepatitis C is a major cause of preventable morbidity and mortality. Prisoners are a key population for hepatitis C control programs, and with the advent of highly effective therapies, prisons are increasingly important sites for hepatitis C diagnosis and treatment. Accurate estimates of hepatitis C prevalence among prisoners are needed in order to plan and resource service provision, however many prevalence estimates are based on surveys compromised by limited and potentially biased participation. We aimed to compare estimates derived from three different data sources, and to assess whether the use of self-report as a supplementary data source may help researchers assess the risk of selection bias. We used three data sources to estimate the prevalence of hepatitis C antibodies in a large cohort of Australian prisoners-prison medical records, self-reported status during a face-to-face interview prior to release from prison, and data from a statewide notifiable conditions surveillance system. Of 1,315 participants, 33.8% had at least one indicator of hepatitis C seropositivity, however less than one third of these (9.5% of the entire cohort) were identified by all three data sources. Among participants of known status, self-report had a sensitivity of 80.1% and a positive predictive value of 97.8%. Any one data source used in isolation would have under-estimated the prevalence of hepatitis C in this cohort. Using multiple data sources in studies of hepatitis C seroprevalence among prisoners may improve case detection and help researchers assess the risk of selection bias due to non-participation in serological testing.

Risk and blood-borne virus testing among men who inject image and performance enhancing drugs, Sydney, Australia

INTRODUCTION AND AIMS

Needle and syringe program (NSP) workers have highlighted that people who inject image and performance enhancing drugs (IPED) in Australia are a younger and more culturally and linguistically diverse (CALD) group compared with other groups who inject drugs. Previous research has found riskier injecting practices and faster Hepatitis C acquisition rates among people who are new to injecting drugs and self-identify with CALD backgrounds, compared with their Anglo-Australian counterparts. Given recent indications of increasing IPED prevalence in Australia and elsewhere, this study sought to update knowledge of infection risk among a large group of IPED injectors, as well as explore sub-group differences.

DESIGN AND METHODS

A cross-sectional survey of men who inject IPEDs was conducted from September 2014 to January 2015 at nine NSP sites, across five local health districts in Sydney, Australia.

RESULTS

Six hundred and five people participated. Small proportions reported previous 12month needle or syringe sharing (2.3%), sharing vials (4.6%), injecting psychostimulants (5.1%) or personal needle or syringe reuse (5.2%). Participants from CALD backgrounds were more likely to report sharing needles or syringes (P = 0.004), and participants from Middle Eastern and North African backgrounds were less likely to have ever been tested for blood-borne viruses, compared with Anglo-Australian participants (P = 0.04).

DISCUSSION AND CONCLUSIONS

The findings show that some groups who inject IPEDs may be more vulnerable to blood-borne virus transmission and/or less likely to know their blood-borne virus status. From design to delivery, IPED harm minimisation strategies should pay attention to the needs of CALD groups.

Hepatitis B virus in drug users in France: prevalence and vaccination history, ANRS-Coquelicot Survey 2011-2013

People who use drugs (PWUD) are a key population for hepatitis B virus (HBV) vaccination and screening. We aimed to estimate the seroprevalence of HBs antigen (HBsAg) and self-reported HBV vaccination history in French PWUD attending harm reduction centres using data from the ANRS-Coquelicot multicentre survey conducted in 2011-2013 in 1718 PWUD. Self-fingerprick blood samples were collected on dried blood spots to detect the presence of HBsAg. HBsAg seroprevalence was estimated at 1·4% [95% confidence interval (CI) 0·8-2·5]. It varied between PWUD born in high (7·6%, 95% CI 2·7-19·1), moderate (2·2%, 95% CI 0·8-5·7) and low (0·7%, 95% CI 0·3-1·5) endemic zones. Factors independently associated with HBsAg carriage were being born in a moderate or high endemic zone or reporting precarious housing. Self-reported HBV vaccination history varied from 47·4% in high endemic zones, to 59·3% and 62·6% for moderate and low endemic zones, respectively. Our results suggest that drug use plays a small and substantial role, respectively, in HBsAg carriage in PWUD born in high/moderate and low endemic zones.

Hepatitis A and B among young persons who inject drugs--vaccination, past, and present infection

BACKGROUND

Our study aims were to assess hepatitis A virus (HAV) and hepatitis B virus (HBV) susceptibility and infection among young persons who inject drugs (PWID) who may have been vaccinated as children and to evaluate self-report of HAV and HBV vaccination.

METHODS

We recruited PWID aged 18-40 years-old in San Diego during 2009 and 2010 and collected demographic, socioeconomic, health, and behavioral factors. Participants were asked if they had been vaccinated against HAV and HBV, and serum samples were collected for HAV and HBV serologic testing.

RESULTS

Of 519 participants, 365 (72%) were male, 252 (49%) were white non-Hispanic, 38 (7%) were Black non-Hispanic, 138 (27%) were White Hispanic, and 22 (4%) were born outside the U. S. Of the total participants, 245 (47%) had surface hepatitis B antibody (anti-HBs) titers <10mIU/ml (i.e., HBV susceptible) and 325 (63%) had no detectable HAV antibodies (HAV susceptible). Hepatitis B surface antigen was detected in 7 (1%) of total participants; and 135 (26%) were anti-HCV-antibody positive. Compared to serologic findings, self-report of HBV and HAV vaccination was 71% and 41% sensitive, and 58% and 73% specific, respectively.

CONCLUSION

HAV and HBV antibodies in half or more of this young PWID population did not have levels indicative of protection, and about a quarter had HCV infection, putting them at risk for complications resulting from co-infection with HAV or HBV. Programs serving this population should vaccinate PWIDs against HAV and HBV and not rely on self-report of vaccination.

Let It "B"? The role of Hepatitis B universal vaccination among italian problematic drug users

Hepatitis B virus (HBV) hepatitis is extremely common among problematic drug users (DUs). As of 2012, 47 of the 53 European countries had implemented a universal hepatitis B vaccination programme, a scenario that could radically change its spread. Even so, drug users are still one of the main groups at risk of being infected by HBV, exposing the fact that universal vaccination still has not managed to reach an optimal level of contagion protection. In order to evaluate the role of universal HBV vaccination in protecting against risk behaviour related to the use of illicit drugs, a group of 748 DUs, 511 male and 237 female, was tested for HBV markers, at their first access to public addiction clinics in the metropolitan area of Bologna, Italy. 487 were born after 1981, so they were eligible to have received HBV vaccination in adolescence or at birth; in these subjects antibodies against HBV core antigen had the significant prevalence of 6.2%. Universal HBV vaccination has shown evidence of protecting against infection in the general population. These results, amongst the first to evaluate actual protection in DUs vaccinated at birth or during adolescence, show that compulsory universal vaccination does not solve the problem of HBV transmission in the most at risk groups and that additional strategies must be studied and implemented to address this issue.

A randomised controlled trial of financial incentives to increase hepatitis B vaccination completion among people who inject drugs in Australia

OBJECTIVE

This study aimed to investigate the efficacy of modest financial incentives in increasing completion of an accelerated 3-dose hepatitis B virus (HBV) vaccination schedule (0, 7, 21days) among people who inject drugs (PWID).

METHODS

Randomised controlled trial. Participants were randomly allocated to receive $30 Australian Dollars cash following receipt of vaccine doses two and three ('incentive condition'), or standard care ('control condition'). Serologically confirmed HBV-susceptible PWID. Two inner-city health services and a field study site in Sydney, Australia. The primary outcome was completion of the vaccination series. Additional assessments included self-reported demographic, drug use and treatment, and risk-taking histories.

RESULTS

Compared to the control condition, significantly more participants in the incentive condition received all three vaccine doses, under intention-to-treat analyses (n=139; 87% versus 66%; p=.004); and within the specified window periods under per protocol analyses (n=107 received three vaccine doses; 92% versus 67%; p=.001). Multivariate analysis indicated that the incentive condition and longer injecting histories significantly increased the likelihood of series completion. Aboriginal/Torres Strait Islanders were significantly less likely to complete the series.

CONCLUSIONS

Modest financial incentives, per-dose, increased adherence to the accelerated HBV vaccination schedule among PWID. Results have implications for increasing HBV and, potentially, other vaccine-preventable infections, among PWID.

Determinants of suboptimal hepatitis B vaccine uptake among men in the Republic of Korea: where should our efforts be focused: results from cross-sectional study

Background

Liver cancer is the second most-frequent cause of cancer death in Korea. Hepatitis B virus (HBV) infection is a major cause of liver cancer, and this disease is effectively prevented by HBV vaccination. This study was conducted to investigate factors associated with the lack of HBV vaccine uptake in the general adult male population in Korea.

Methods

Data of men who participated in a nationwide cross-sectional interview survey were analyzed. A total of 2,174 men 40 years of age and older were interviewed between 2006 and 2008. None of the participants was infected with HBV or was experiencing sequelae of an HBV infection.

Results

Only half (50.4%) of the men received one or more dose of the three-dose series of HBV vaccinations, and 32.5% received all three doses. Compared with men who had completed the vaccination regimen, non-vaccinated men were more likely to lack supplemental medical insurance for cancer (odds ratio = 0.66, 95% confidence interval: 0.52–0.84), have lower incomes (p-trend = 0.010), and be less educated (p-trend = 0.021). Lower education was also more prevalent in the non-vaccinated group compared with the incompletely vaccinated group. Those who had completed the vaccination regimen were likely to be more educated than those in the incompletely vaccinated group (p-trend = 0.044). The most commonly cited reason for not obtaining the HBV vaccine was lack of knowledge regarding the need for the vaccination. The number of men who cited this reason decreased as a function of education.

Conclusions

It is important to develop strategic interventions targeted at less-educated men to increase uptake of a complete three-dose series of HBV vaccinations as a primary approach to preventing liver cancer.

Hepatitis B screening: who to target? A French sexually transmitted infection clinic experience

BACKGROUND & AIMS

Hepatitis B virus (HBV) infection is a major public health burden in France and worldwide. Routine screening for hepatitis B is not currently recommended in France. Medical experts and public health agencies opinions can differ concerning targeting criteria. Our study aims at developing a risk assessment strategy for identifying possible hepatitis B cases among the patients consulting in a French Sexually Transmitted Infection (STI) clinic.

METHODS

6194 asymptomatic patients requesting an STI screening were also screened for hepatitis B infection. The association between hepatitis B surface antigen (HBsAg) positivity and/or total hepatitis B core antibody (anti-HBc) positivity and self-reported risk factors for hepatitis were analysed.

RESULTS

Only male gender, lack of employment, and birth, in medium or high endemic country, were independently associated with HBsAg positivity in multivariate analysis. Sexual behaviour or self-reported vaccination status is therefore not necessary to target high-risk populations. These three simple criteria could save 25% of unnecessary tests and 6-16% undiagnosed hepatitis B compared to usual targeting criteria.

CONCLUSIONS

To detect HBsAg carriers, only three simple targeting criteria, without taking into account the self-reported vaccination status or sexual behaviour, could improve screening efficiency and save unnecessary testing.

Hepatitis B virus exposure and vaccination in a cohort of people who inject drugs: what has been the impact of targeted free vaccination?

BACKGROUND AND AIM

Forty percent of new hepatitis B virus (HBV) infections in Australia occur in people who inject drugs (PWID); long-term infection carries the risk of serious liver disease. HBV incidence among Australian PWID has not been measured since the advent of targeted (2001) and adolescent school-based "catch-up" (1998) vaccination programs. We measured HBV incidence and prevalence in a cohort of PWID in Melbourne, Australia and examined demographic and behavioral correlates of exposure and vaccination.

METHODS

Community-recruited PWID were surveyed about blood-borne virus risk behaviors and their sera tested for HBV markers approximately three-monthly over three years. Incidence was assessed using prospectively collected data. A cross-sectional design was used to examine prevalence of HBV exposure and vaccination at baseline. Poisson regression was used to identify correlates of HBV exposure and vaccination.

RESULTS

At baseline, 33.1% of participants (114/344) had been vaccinated against HBV, 40.4% (139/344) had been exposed (previously or currently infected), and 26.5% (91/344) were susceptible. HBV incidence was 15.7 per 100 person-years. Independent associations with HBV exposure included female gender, South-East Asian ethnicity, drug treatment in the past three months, injecting in prison, and prior exposure to hepatitis C virus. Independent associations with vaccination included being ≤ 25 years old, reporting HBV vaccination, and never having been to prison.

CONCLUSIONS

HBV infection continues at high incidence among Australian PWID despite the introduction of free vaccination programs. Innovative methods are needed to encourage PWID to complete HBV vaccination.

Gender differences in hepatitis C seroprevalence and suboptimal vaccination and hepatology services uptake amongst substance misusers

Injecting drug users are the principal at risk group for blood borne viruses. The aim was to assess the feasibility of screening substance misusers for blood borne viruses, and to offer appropriate vaccinations/referral to hepatology services. This was a nurse led prospective 6-month study based at a large Substance Misuse Service in south east England. Of the 196 consecutive individuals assessed, 81 were eligible for HBV immunization of whom only 33.3% completed a vaccination course. Prevalence of positive serological markers were: anti-HBc 14.4%, HBsAg 1.5%, and HCV antibody 37.9%. Compared to men, women were more likely to accept blood borne virus testing (83.3% vs. 62.3%), have ever injected (89.6% vs. 76.3%), overdose (54.2% vs. 23.6%), be anti-HBc positive (27.5% vs. 8.8%), drink alcohol above national recommended guidelines (41.7% vs. 25.7%), and have a positive HCV serology (55% vs. 30.4%) (P ≤ 0.05 for all). Of the 73 individuals identified with a positive HBsAg and or HCV antibody, only 14 (19.1%) were known to hepatology services and 8 (20%) of those eligible subsequently accepted a specialist referral. In conclusion, serological markers for blood borne viruses remain high in substance misusers (anti-HBc 14.4%, HCV antibody 37.9%), with women more likely to be positive. Overall, only 33.3% and 20%, respectively, complete HBV vaccination and accept a hepatology referral. A multidisciplinary approach is paramount to address both the blood borne viruses and the substance misuse and realignment of hepatitis services to Substance Misuse Services may offer such a strategy.

Correlates of susceptibility to hepatitis B among people who inject drugs in Sydney, Australia

Despite a safe, effective vaccine, hepatitis B virus (HBV) vaccination coverage remains low among people who inject drugs (PWID). Characteristics of participants screened for a trial investigating the efficacy of financial incentives in increasing vaccination completion among PWID were examined to inform targeting of vaccination programs. Recruitment occurred at two health services in inner-city Sydney that target PWID. HBV status was confirmed via serological testing, and questionnaires elicited demographic, drug use, and HBV risk data. Multinomial logistic regression was utilized to determine variables independently associated with HBV status. Of 172 participants, 64% were susceptible, 17% exposed (HBV core antibody-positive), and 19% demonstrated evidence of prior vaccination (HBV surface antibody ≥ 10 mIU/ml). Compared with exposed participants, susceptible participants were significantly more likely to be aged less than 35 years and significantly less likely to be receiving current opioid substitution therapy (OST) and to test hepatitis C antibody-positive. In comparison to vaccinated participants, susceptible participants were significantly more likely to be male and significantly less likely to report daily or more frequent injecting, current OST, and prior awareness of HBV vaccine. HBV vaccination uptake could potentially be increased by targeting younger, less frequent injectors, particularly young men. In addition to expanding vaccination through OST, targeting "at risk" youth who are likely to have missed adolescent catch-up programs may be an important strategy to increase coverage. The lack of an association between incarceration and vaccination also suggests increasing vaccination uptake and completion in adult and juvenile correctional facilities may also be important.

Concordance between self-reported and actual hepatitis C virus infection status in a cohort of people who inject drugs

INTRODUCTION AND AIMS

Accurate knowledge of individual hepatitis C virus (HCV) status is an important component of comprehensive health services for people who inject drugs (PWID). In this paper we compare the perceived HCV status of PWID in a longitudinal cohort study with their actual status, as verified by HCV-RNA testing.

METHODS

Participants who consented to blood testing at first follow up (352/688) were included. Self-reported HCV status (positive/negative/don't know), was compared with serology test results for participants.

RESULTS

In comparing self-report with HCV-RNA results, 274 of 352 participants had valid serology and self-report results; of these, 220 (80%) accurately reported their HCV status.

DISCUSSION AND CONCLUSIONS

The findings of this study suggest that large proportions of PWID know their true HCV infection status, but the discordant participants represent potential HCV infection risks. Despite the majority of participants displaying concordance, this study reinforces the need for regular blood testing and the giving of accurate, practical and comprehensive HCV result information.

Development of a nurse-led primary healthcare service for injecting drug users in inner-city Sydney

Injecting drug users (IDUs) experience numerous health problems, but report barriers to utilising general practitioners (GPs). A nurse-led Harm Minimisation-based Primary Healthcare (HMPH) service for IDUs was established within a needle and syringe program in inner-city Sydney with Area Health Service medical support and clinical governance. This paper aimed to describe the HMPH service, review service utilisation and assess nurses’ perceptions of their work with IDUs. A review of the most recent 200 clinic files was undertaken. Service utilisation, GP and other health service use and access were extracted and analysed using SPSS. A semi-structured qualitative interview with clinic nurses regarding their experience working with IDUs and local GPs was conducted and analysed. Since its inception in mid-2006, the service has been utilised by 417 clients. Of the most recent 200 files, blood-borne virus and sexually transmitted infection screening were the primary reason for presentation (64.5%). At least one follow-up visit was attended by 90% of clients. A total of 62% of clients reported consulting a GP in the last 12 months. The service provided 102 referrals. Nurses believed that IDUs tend to utilise GPs ineffectively and that self-care is a low priority, but that they can support IDUs to overcome some barriers to GPs and facilitate access. Targeted primary health care services led by nurses with focussed medical support and co-located with needle and syringe programs can fill an important gap in delivering and facilitating health care to IDUs.

The self-reported personal wellbeing of a sample of Australian injecting drug users

AIMS

To examine the self-reported personal wellbeing of a sample of Australian injecting drug users (IDU) using a standardized instrument and determine the key correlates of variations in self-reported personal wellbeing.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional survey of 881 Australian IDU.

MEASUREMENTS

Self-reported personal wellbeing collected using the Personal Wellbeing Index (PWI).

FINDINGS

IDU scored significantly lower than the general Australian population on the PWI and all subscales. Lower PWI scores were associated with a range of socio-demographic, drug use and other health and social characteristics. Across all PWI subscales, lower personal wellbeing scores were associated with unemployment, past 6-month mental health problems and more frequent injecting (all P < 0.05).

CONCLUSIONS

The PWI is sufficiently sensitive to distinguish between IDU and the general population, and to identify key correlates of PWI among IDU. Some domains canvassed within the scale, such as health, standard of living and life achievements, are well within the scope of current intervention strategies, such as pharmacotherapy maintenance treatment and housing and employment support services. This suggests that the PWI could be useful in clinical settings by allowing structured identification of the areas of a person's life to be addressed as a part of a treatment regimen. In order to inform targeted prevention and intervention efforts, longitudinal studies of PWI and its correlates among IDU are required.