Despite public health recommendations1 that people who've contracted the chronic form of hepatitis C (HCV) be vaccinated against the hepatitis A virus (HAV), a new study found that it happens rarely.2
"Based on the potential risk for fulminant [liver] failure and death from acute HAV superinfection, the 1996 Advisory Committee on Immunization Practices recommended HAV vaccination for all patients with chronic liver disease, including those with chronic HCV infection," wrote Edmund Bini, MD, MPH, a gastroenterologist who headed this study, and a group of colleagues.
Assessing HAV Vaccination Practices
Bini and fellow researchers in the VA New York Harbor Healthcare System and at NYU School of Medicine pulled the records of all those who underwent HCV antibody testing in 2000 to determine how often any of them underwent vaccination for the hepatitis A virus.
Among other things, Bini and his team collected information on each patient's age, sex, race, injection drug use, alcohol consumption whether they had sex with a same-sex partner, history of STDs, and whether they had been diagnosed with liver cirrhosis.
The researchers found that more than 8,200 patient underwent HCV antibody testing during the year on which the study focused. Of those, 1,363 tested positive for hepatitis C infection, 1,193 of whom were infected chronically, and thus were included in the research. Most of the patients were men, and histories of injection drug use, alcohol abuse, and psychiatric disorders "were highly prevalent", the research team wrote.
Vaccinations Occurred in Few Cases
Bini and his team discovered that these patients had visits with their primary care providers, including gastroenterologists in some cases, but that just over half of the 1,193 patients had undergone tests for hepatitis A. Those with a prior history of STDs and those seen in the gastroenterology clinic of the hospital included in the study were more likely to be tested.
Among those tested for HAV, it was found nearly half of them were susceptible to the virus, though that was seen less often in older patients. Women more than men were more susceptible, as were those who had used injection drugs. Those with a history of homosexual intercourse and a prior STD were less susceptible.
Bini and his group also found that despite the fairly significantly susceptibility to HAV, only 94 of the 1,193 patients with chronic hepatitis C infection had received the HAV vaccine during the study year. Of those, only half received just one dose. Eighty-five patients who were HAV susceptible, three who were already immune to hepatitis A, and six who had never undergone HAV testing had been vaccinated.
Those who had undergone HAV testing previously were more likely to have been vaccinated, Bini and his team found, as were young patients, patients with cirrhosis, and those who had been seen in the hospital's gastroenterology clinic, among other things.
Of those with chronic HCV infection, three developed acute hepatitis A infection later.
Low Number of Vaccinations is 'Striking'
"In a large retrospective cohort study, we showed that a substantial proportion of patients with chronic HCV infection did not have HAV antibody testing performed, and most of the susceptible patients were never vaccinated against HAV," Bini and his colleagues wrote. "The low rates of HAV testing and vaccination are striking, given the presence of recommendations to vaccinate these individuals against HAV since 1996, the long duration of follow-up, and the high number of visits with their primary care provider."
"These findings have substantial public health implications and represent missed opportunities for prevention," they added.
Possible Reasons for Rare Vaccinations
While the actual reasons why these patients were never vaccinated aren't known, the study team pointed out, they speculated that it could have been due to a lack of awareness that the vaccine was necessary, beliefs that the patients did not face a significant risk of HAV infection, doubts about vaccine effectiveness, misperceptions about side effects, or fear of needles.
"Alternatively, it is possible that HAV vaccination was not offered by providers because of the need to address other more important issues," they wrote. These include issues like inadequate reimbursement, lack of knowledge about whom to vaccinate, or beliefs that the vaccination may not be safe, effective, or cost-effective in this group of patients.
"However, several studies have shown that vaccination against HAV is safe and effective in patients with chronic liver disease, especially in whose with well-compensated liver disease," Bini's group pointed out.
Hepatitis A Prevalence
According to the study team, there were 180,000 cases of hepatitis A in the United States in 1997, the latest year for which statistics are available. HAV superinfection can cause severe liver disease, acute liver failure, and it increases the risk of death in people with underlying chronic liver disease. Symptoms of hepatitis A include jaundice, fatigue, abdominal pain, loss of appetite, nausea, fever, and diarrhea.3
Those most at risk include coming into contact with others in your household who have hepatitis A, sexual contact with infected people, men who have sex with men, and injecting and non-injecting illicit drug users.3
"Public health efforts at raising awareness about HAV vaccination in patients with chronic liver disease should be strongly encouraged," wrote Bini's group. "In addition, further studies to evaluate patient and provider barriers to HAV vaccination are needed to prevent future missed opportunities for vaccination."
1. Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1996 Dec 27;45(RR-15):1-30.
2. Shim M, Khaykis I, Park J, Bini EJ. Susceptibility to hepatitis A in patients with chronic liver disease due to hepatitis C virus infection: missed opportunities for vaccination. Hepatology 2005 Sep;42(3):688-95.
3. Centers for Disease Control and Prevention. Viral Hepatitis A Fact Sheet. Available at: http://www.cdc.gov/ncidod/diseases/hepatitis/a/fact.htm. Accessed September 14, 2005.
John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include overseeing health news coverage for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.
