Original Research

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

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

References

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Patient Identification and Education

All program participants were offered testing for HIV and hepatitis A, B, and C. Program participants were educated about hepatitis and HIV transmission, as well as about the long-term effects of continued substance abuse on the progression of hepatitis C. Education about hepatitis, HIV, and substance abuse was provided in a group setting by a member of the program’s nursing staff. One-on-one risk education counseling was also provided when requested or otherwise indicated.

Laboratory testing was performed following each participant’s initial physical examination (within 3 to 5 days of program admission), and the nursing staff reviewed the results before vaccination. Explanation of laboratory results and an individualized immunization regimen were provided to each participant. On review of participants’ laboratory results, those with seroconversion of both hepatitis A and B were not given the combined immunization. Participants who had seroconversion of hepatitis A were offered the hepatitis B vaccination series, and vice versa.

Immunization Process

Participants who lacked prior immunization for hepatitis A and B and had no seroconversion of either hepatitis A or B were offered vaccination. Some patients declined vaccination, even though they were eligible. Their reasons were not formally assessed.

Patients who accepted the vaccination were given the accelerated regimen.¹⁶ Participants were educated on the importance of compliance with the vaccination series and provided with follow-up immunization dates and a reminder for the 1-year booster vaccine. The immunizations were ordered by the program’s primary care NP and administered by a licensed practical nurse. The nurse who administered the injections took responsibility for scheduling the patients for all their subsequent injections, including the 1-year booster.

Follow-up Care

If the third injection was not completed before discharge, patients were given a follow-up appointment with the nurse if they remained in the JAHVH service area. If they were leaving the area, they were given instructions on how to follow-up at another VA facility to continue their immunization schedule. A note was written in the electronic medical record documenting their abbreviated hepatitis A/B immunization schedule, which could be accessed by other providers at other VA facilities. Patients who did not show up for any follow-up appointments (third injection or the 1-year booster injection) were contacted and reminded about the importance of completing the immunization series and to schedule an appointment.

Statistical Analysis

All data were analyzed using IBM Statistical Package for the Social Sciences (IBM SPSS, Armonk, New York) with a focus on identifying differences between vaccination-eligible patients (n = 269) who did (n = 128) and did not (n = 141) initiate the immunization schedule during the treatment program. Chi-square and Fisher exact tests were used to assess statistical differences in initiation of the immunization schedule related to categoric variables (ie, marital status, race, history of IV drug abuse, cigarette smoking status, housing status, legal status, history of combat, having a psychiatric or medical diagnosis, and program track). Independent sample t tests were used to test for differences between these 2 groups on the continuous variables, including age, number of previous treatment programs, Global Assessment of Functioning score, severity of smoking dependence as measured by the Fagerström Test for Nicotine Dependence, and the Addiction Severity Index scales.^18-20

Results

The sample consisted of 284 successive admissions to an intensive outpatient program for veterans with substance use disorders. About one-third of the patients were homeless at the time of admission to the treatment, and 87% required contracted housing while completing treatment for reasons related to lack of housing, transportation, clinical necessity, or a combination of those factors (Table 1). The most common substance problems were alcohol and cocaine dependence, and 21% (n = 59) of the patients acknowledged a history of IV drug use during their initial psychiatric evaluation. Seventy percent were dually diagnosed with some other Axis I disorder, and 40% had a history of serious mental illness. More than one-fourth (n = 77) of the patients admitted to the intensive outpatient SATP were seropositive for hepatitis A, B and/or C, and the most common hepatitis diagnosis was hepatitis C (n = 71).

Accelerated Immunization Regimen

Patients were eligible to receive the accelerated vaccination schedule only if they had no prior immunization for hepatitis A or B and if they had no seroconversion for either hepatitis A or B. Six people had hepatitis B alone, 7 had hepatitis B and C, 1 had hepatitis A and C, and 1 had all 3 (Table 2). Thus, 15 participants were ineligible to receive the accelerated hepatitis A/B immunization. Chi-square, Fisher exact, and independent sample t tests showed that among those who were vaccination-eligible (269), there were no significant differences in any of the demographic or clinical characteristics between those who initiated the vaccination schedule and those who did not. Among those who completed the first 3 vaccine injections, those who received the 1-year booster injection (54) did not differ (on any demographic or clinical variables) from those who did not (58).