Hepatitis B virus infection in patients attending a genitourinary medicine clinic: risk factors and vaccine coverage

Abstract

Background:The hepatitis B virus (HBV) immunisation policy in the United Kingdom includes oVering vaccine selectively to those at risk by sexual contact. Among genitourinary medicine (GUM) clinic attenders, homosexual men are oVered vaccine, but estimates of the vaccine uptake are required to monitor policy and estimate the possible impact on transmission; heterosexuals are not routinely oVered vaccine, but this policy might change if the prevalence was found to be high. Objective: To determine the prevalence of HBV infection and vaccine uptake among patients attending a GUM clinic. Methods: HBV seroprevalence determined by unlinked anonymous testing of consecutive blood samples sent for syphilis serology. Demographic and risk factor data and history of HBV immunisation extracted from clinic notes before unlinking. Prevalence data were compared with a population of first time blood donors from the same area. Setting: Open access GUM clinic in central London. Results: Samples were obtained and tested from 441 homosexual and 527 heterosexual men and from 821 women over a 4 month period in 1990. After exclusion of injecting drug users and their sexual partners (n=30) and HBV carriers attending for follow up (n=12), the prevalence of antibody to HBV core (anti-HBc) was 38.7% in homosexual men, 5.9% in heterosexual men, and 3.5% in women (50.0%, 6.0%, 3.7% respectively if previous vaccinees were also excluded). The prevalence of HBV surface antigen positivity was 4.2%, 0.60%, and 0.39% respectively after exclusion of vaccinees ( 2 p<0.001 for homosexual men versus others). The prevalence of antiHBc in first time blood donors was 1.1% (8/749). Among male GUM clinic attenders, the prevalence of anti-HBc was higher in those of non-UK origin or place of birth and/or non-white ethnicity (odds ratios 2.87, 95%CI 1.57-5.24 and 8.06, CI 3.39-19.1, in homosexuals and heterosexuals respectively). In homosexual men anti-HBc prevalence increased with age (OR 1.05, CI 1.02-1.07 for each year) and lifetime number of STDs (OR 6.36, CI 3.77-10.8 for >2 versus <2) and in clinic reattenders compared with new patients (OR 5.42, 95% CI 3.32-9.16). Among heterosexuals, age was associated with anti-HBc prevalence in women (OR 1.09, CI 1.04-1.12) but not men (OR 0.99, 95% CI 0.95-1.02). There were no other associations in heterosexuals. A history of HBV immunisation in homosexual men was recorded in 13/131 (9.9%) of new patients and 103/305 (33.8%; OR 4.63, CI 2.49-8.60) clinic reattenders. Conclusions: Although higher than a sample of blood donors, the prevalence of serological markers of HBV infection among heterosexuals was low, providing little support for extending HBV immunisation to all heterosexuals attending GUM clinics as a targeted strategy for control of HBV infection. Homosexual men remain at high risk of infection, but many are now being immunised. EVorts to improve compliance with existing vaccine policies in GUM clinics should be encouraged. (Sex Transm Inf 1998;74:110-115)

Incidence and routes of transmission of hepatitis B virus in England and Wales, 1995–2000: implications for immunisation policy

“…Both observations suggest that the transmission rate through male homosexual contact is decreasing, and contrasts with the current increase in high risk sexual behaviour and outbreaks of other sexually transmitted infections among MSM (PHLS, 2002). The decreased incidence of HBV in MSM is likely to be attributable to increased HBV vaccine coverage in this group, which is consistent with information from surveys among MSM attending GUM clinics (Gilson et al, 1998). Coverage among MSM is being improved by offering HBV vaccine to all MSM attending GUM clinics, with central purchase and supply of vaccine, and clear coverage targets being set (Department of Health, 2001).…”

Hepatitis B infection among patients attending a sexually transmitted diseases clinic in Rio de Janeiro, Brazil

“…Although the heterosexual transmission of HBV is related as more frequently than homosexual transmission (Alter 1990, Duarte 1992, recent studies in STD clinics (Stroffolini et al 1997, Gilson et al 1998 showed the opposite. In answering about homosexual behaviour, 3.6% of the 2000).…”

“…In areas of low endemicity the sexual contact is the major route of transmission. Extensive studies regarding HBV sexual transmission have been conducted in low HBV endemic countries (Struve et al 1993, Gilson et al 1998. Heterosexuals who have unsafe sex with multiple partners and homo/bisexual men are the high-risk groups for sexual transmission (Margolis et al 1991).…”

Economic evaluations of hepatitis B immunization: a global review of recent studies (1994–2000)

“…On the one hand, low attendance rates in genitourinary medicine (GUM) clinics and poor vaccination coverage of IDUs reported in several papers have been used to call into question the feasibility of selective vaccination [44][45][46][47], and to raise the issue of whether heterosexuals who attend GUM clinics, should also be vaccinated [48]. On the other hand, the observed reduction in the incidence of acute HBV in very low and low endemic countries before the era of universal vaccination has been interpreted indicating that selective vaccination strategies could be sufficient in these countries [49].…”