An audit of hepatitis B vaccination for men who have sex with men before and after sexual health service integration

Introduction

In Scotland, hepatitis B vaccination of men who have sex with men (MSM) has been identified as one of the five key clinical indicators of successful sexual health service provision, ¹ informing the development of Healthcare Improvement Scotland (HIS) standards. Standard 7.3 requires that 70% of MSM attending specialist sexual health services who are not known to be immune to hepatitis B should receive at least one vaccine dose. ² National audits have shown high vaccination rates of MSM in genitourinary medicine (GUM) clinics across Scotland, ³ and local audit in Lothian demonstrated a 98% uptake in eligible males. ⁴ The super-accelerated (0, 1, 3 and 52 weeks) vaccination schedule is offered as standard to MSM in Lothian, and this study examined provision of the first three doses of this vaccination schedule.

Sexual health services in Lothian underwent a process of redesign commencing with a period of integration training for GUM and sexual and reproductive health (SRH) staff teams in March 2011, with the opening of the unified purpose-built Chalmers Sexual Health Centre (CSHC) in June 2011.

There is evidence that generic sexual health services are not well equipped to serve the needs of MSM. ⁵ This audit was performed to ensure that the required standard was achieved, and previous high levels of vaccination were maintained pre-integration. The re-audit was undertaken to assess vaccination rates immediately post-service redesign, as a marker of the quality of care provided to MSM in a newly integrated service.

Methods

Pre-integration, new episodes of care in Lothian for MSM between 1 January and 30 June 2010 were identified from the standardised national clinical coding database (STISS). Post-integration data were obtained using the NHS Scotland National Sexual Health system (NaSH) to identify new episodes of care for MSM between 1 April and 31 October 2011. Individual patient records, laboratory data and prescribing records were queried for each audit cycle to identify eligibility and provision of vaccine doses. The criteria used to determine new episodes using the NaSH system are derived from the STISS criteria, and the STISS coding criteria were applied to the vaccination and serological data derived from NaSH to ensure that the samples were comparable. Lifetime partner gender is part of the national minimal clinical dataset and is reliably recorded in men across the service. Eligible patients had negative baseline hepatitis B virus (HBV) serology (Anti-HBc negative, HBV sAg negative), with no history of vaccination (positively recorded as part of a minimal dataset). Patients with a lapsed course of vaccination were excluded. Those known to be infected with HIV and/or hepatitis C were excluded because these cohorts continued to be reviewed in specialist clinics where staffing and clinic protocols remained wholly unchanged after integration, and because regular attendance for care and intensive follow up for non-attendance means that vaccination rates in these cohorts are likely to be higher than for MSM as a whole.

Results

Post-integration: 2011

Both pre- and post-integration a dedicated MSM drop-in clinic existed, but over two-thirds of MSM attendees in both audit cycles were seen in the general clinic by the combined staff team. A total of 343 male patients were identified as being MSM registering with CSHC for a first episode of care. A larger proportion of these men had previously attended services in Lothian or elsewhere for care, so only 87 (25.3%) were identified as eligible for vaccination. Of these, 78 (89.7%) received at least one dose of vaccine (Table 1) and 30 patients completed the first three doses of the super-accelerated vaccination course (34.5%; Table 2).

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Table 1.

Number of patients receiving at least one HBV vaccination.

	Eligible and had at least one vaccine dose	Eligible and did not have vaccination	Total
Pre-integration	130 (87.0%)	20 (13.0%)	150
Post-integration	78 (89.7%)	9 (10.3%)	87
Total	208	29	237

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Table 2.

Number of patients receiving the first three doses of the super-accelerated course of HBV vaccinations.

	Eligible and had less than three vaccine doses	Eligible and had three vaccine doses	Total
Pre-integration	74 (49.3%)	76 (50.7%)	150
Post-integration	57 (65.5%)	30 (34.5%)	87
Total	131	106	237

There was no significant difference between the proportion of men receiving at least one dose of vaccination pre- and post-integration (130/150 = 87.0% vs. 78/87 = 89.7%, p = 0.64, χ²= 0.222; Table 1). There was, however, a significant decrease in the proportion of men receiving three doses of vaccination pre- and post-integration (76/150 = 50.7% vs. 30/87 = 34.5%, p = 0.0157, χ²= 5.834; Table 2).

Conclusion

This audit shows that sexual health services in Lothian surpassed the HIS standard for provision of at least one hepatitis vaccine dose in both pre- and post-integration periods, with no significant difference between the periods. Provision of at least three doses was significantly lower in the post-integration period. This may reflect differences in access to the service or potentially the acceptability of the service to MSM following an initial visit. The completion rates for the fourth dose of the super-accelerated course remain unknown. There is evidence that one or two doses of vaccination can offer clinically significant protection against hepatitis B infection in MSM^6,7 and data from the Netherlands suggest that a programme in which 75% of men receive three doses of vaccine has an impact at the population level. ⁸ It is not, therefore, clear what the clinical significance of a reduction in rates of attendance for second and subsequent doses of vaccination may be, but it deserves examination in case it indicates a change in accessibility to or acceptability of services. There is no evidence locally of an increase in the number of reported acute hepatitis B cases.

As described, one third of MSM attendees at CSHC utilise our MSM-specific drop-in clinic, a service where there was a less marked shift in staffing after the integration process. Vaccination rates in different elements of the service were examined in detail in the first cycle of audit (not shown), and there was no difference in rates between the general clinic, the specialist MSM clinic and outreach services.

As a retrospective audit, data collection was reliant on accurate and full documentation, completion of data sets identifying eligible men, and of prescription of vaccines administered. It is possible that identification of MSM might have diminished due to reduced recording of partner gender in the integrated service and explains the smaller number of eligible MSM in the second-audit cycle – however, we do not think that this is the case because (1) the number of MSM attendees to the service has consistently increased and (2) the number and proportion of MSM attendees recorded as bisexual (who might be anticipated to be more likely to be misidentified) has also increased.

Vaccination against hepatitis B has been used in this study as a surrogate marker of comprehensive sexual health services for MSM. Although there is a paucity of literature as to the appropriateness of its use in this way, there are also few well-validated alternative markers.

The process of integrating GUM and SRH services is challenging, and the move from caring almost exclusively for women to seeing MSM was a major change in practice and culture for some team members. These audit data support patient feedback and experience data, suggesting that, that in terms of initial access to care and completeness of the care given, MSM do not appear to be disadvantaged by service integration. It is not clear whether the reduced attendance for further vaccination is due to access, acceptability issues or other factors such as a reduced priority placed on active recall of MSM for vaccination due to other service pressures. Completion of a further audit cycle would help to answer some of these questions.