Vaccination against hepatitis B in an HIV outpatients' department: an audit against national vaccination guidelines

INTRODUCTION

There is known high morbidity associated with co-infection with hepatitis B and HIV ¹ and yet hepatitis B is potentially preventable with successful vaccination. The British HIV Association (BHIVA) has produced clear guidance on vaccinations for patients with HIV, which includes hepatitis B vaccination. ² We performed an audit of hepatitis B vaccination in our HIV outpatients department against the BHIVA guidelines, both before and after the introduction of a vaccination record sheet in the outpatient notes, to assess the impact, if any, of this intervention.

METHODS

Case notes of 103 HIV outpatients (4% of a total cohort size of 2700 patients) were selected at random and reviewed between 1 December 2007 and 31 January 2008. The findings from the initial audit were presented to the HIV department and a single-page hepatitis vaccination record sheet was then introduced into all HIV outpatient notes in July 2008. This record sheet included documentation of all baseline hepatitis B serological results (performed at a patient's initial visit) and annual hepatitis B surface antibody (HBsAb) levels and dates of administration of any booster vaccines. Case notes of 100 HIV outpatients were then selected at random and reviewed between 1 December 2008 and 31 January 2009. Numbers in each audit group were small due to limited time and resources available. For each patient, the following data were recorded and analysed in Microsoft Excel^®: age, gender and ethnicity of patient, baseline CD4 count, time since diagnosis of HIV, time between diagnosis and first outpatient visit, evidence of baseline screening for hepatitis B status at HIV diagnosis, appropriateness of follow-up once hepatitis B status known, i.e. whether or not patient received vaccination if required, whether the patient received all three doses of hepatitis B vaccination and if HBsAb levels were checked following vaccination.

By the time of the re-audit, the department had commenced a new policy of vaccination of those with a CD4 count of <500 cells/mL with a higher dose of vaccination, owing to recent data that had showed improved HBsAb levels with this approach. ^3,4 Data on whether the appropriate dose of vaccine had been given were therefore collected for patients in the re-audit.

RESULTS

The audit assessed a total of 103 and 100 patients in the initial and re-audits, respectively. Baseline demographic data were representative of our clinic population and were comparable in the two groups, apart from median baseline CD4 counts, which were 317 cells/mL (range 6–1013) and 572 cells/mL (range 16–1631), respectively. In the initial audit, median time since diagnosis was 78.0 months (range 2–276 months) with 9.7% (10/103) patients diagnosed ≤6 months previously. In the re-audit, the median time since diagnosis was 58.0 months (range 4–289 months) with 12% (12/100) patients diagnosed ≤6 months previously.

Data on the interval between first hepatitis B serology and the audit period were available for 80/103 patients in the original audit and for 91/100 in the re-audit, and was median of 31.3 months (range 1–185 months) and 12 months (range 1–132 months), respectively.

In the initial audit, 60/103 patients (58%) were assessed for their hepatitis B serological status at time of HIV diagnosis (Table 1). This improved to 70/100 (70%) in the re-audit (P = 0.11, Fisher's exact test). Forty-eight patients were identified as requiring vaccination in the initial audit, and of these 34/48 (71%) had vaccination courses commenced and 32/48 (67%) completed three doses of the vaccination. In the re-audit, 68 patients were identified as requiring vaccination, and of these 64/68 (94%) had vaccination courses commenced and 54/68 (79%) completed three doses of the vaccination (P = 0.09). In the initial audit, 14/48 (29%) patients were subsequently followed up with HBsAb levels at six weeks post-vaccination. This improved to 34/68 (50%) in the re-audit (P = 0.03). When combined with those patients who did not require vaccination (those who were hepatitis B surface antigen and/or hepatitis B core antibody positive, or who had been previously vaccinated), the total number of patients followed up in line with BHIVA guidance was 34/103 (33%) in the initial audit, improving to 61/100 (61%) in the re-audit (P < 0.005).

The type of vaccination schedule received by the patients was not recorded in the original audit and so was unavailable for analysis. In the re-audit, vaccination dose data were available for 55 patients: 29 patients (52.7%) received the ultra-rapid schedule (0, 1 and 3 weeks as per current clinic policy), 22 (40.0%) received the accelerated schedule (0, 1 and 2 months) and four patients (7.3%) received the traditional schedule (0, 1 and 6 months). Of note was that in the re-audit for those with data available (55 out of 100 patients), 41 patients (74.5%) received the appropriate dose of vaccination as directed by their most recent CD4 count.

In the original audit, there were 14 patients with a most recent HBsAb level <10 mIU/mL (of whom none went on to have repeat vaccination) compared with 44 in the re-audit (of whom 5 [11%] went on to have repeat vaccination). In the original audit, 10 patients received booster vaccinations compared with nine patients in the re audit, although data were not complete for this part of the audit for either group.

DISCUSSION

Having identified a need for improvement in our HIV outpatient vaccination service, we have demonstrated that the introduction of a simple reminder in the form of a vaccination record sheet improved vaccination completion rates from 67% to 79%. We also improved standard of care for all our patients such that adherence to BHIVA guidelines improved from 33% to 61%. However, it is worth noting that these results still fall somewhat short of recommended vaccination completion and follow-up rates and that there is still room for improvement in our outpatient cohort. Two measures that improved between audits but not to a statistically significant level were percentage of patients screened for hepatitis B at their initial visit and completion of three doses of vaccination. Of particular concern was that baseline hepatitis serology testing was low and improved to only 70% in this large London teaching hospital. These results were fed back to the department as an area for targeted improvement. Also of note was that the response rates as measured by HBsAb levels six weeks post-vaccination were much lower in the re-audit group compared with the original audit, despite a higher average baseline CD4 in the re-audit group. One reason for this may have been the high rate of ultra-rapid vaccination schedule use in the re-audit, although sadly the rates of schedule use in the original audit were not available for comparison. This finding clearly warrants further study.

HIV outpatients require a great deal of monitoring, risk assessments and follow-up and it is easy to miss important interventions due to workload and time constraints. Interventions such as our record sheet and automated reminders may enable us to provide more comprehensive care for these patients to keep them healthy in the longer term.