Nivolumab is now approved to treat metastatic squamous non-small cell lung cancer, although adverse effects such as serious immune-mediated...
Dr. Winn is a clinical psychologist, Dr. Francis is an attending psychiatrist, Dr. Shealy is a clinical psychologist, Ms. Paton is a retired licensed practical nurse, Ms. Planner is a retired registered nurse, Ms. Kelly is a retired registered nurse, and Dr. Gonzales-Nolas is an attending psychiatrist, all at the James A. Haley Veterans’ Hospital in Tampa, Florida. Ms. Levarge is an advanced registered nurse practitioner at American Lake Division of the VA Puget Sound Healthcare System in Lakewood, Washington. Dr. Winn is an assistant professor, Dr. Francis is an associate professor, Dr. Shealy is an assistant professor, and Dr. Gonzales-Nolas is an assistant professor, all at the University of South Florida in Tampa.
Homeless individuals and IV drug users are susceptible to hepatitis A, B, and C infections, and co-infection with these diseases may complicate treatment and result in poor medical outcomes.1 Vaccination offers the best protection against hepatitis A and B, particularly among high-risk populations.2,3 Immunization against hepatitis A and B is of even greater importance for patients with hepatitis C, because there is no specific hepatitis C vaccine, and concomitant infections of B with C are damaging to the liver.4
Veterans have a rate of hepatitis C infection that is 3 times that of the general population.5 Some evidence exists that veterans with serious mental illness (SMI) have a higher rate of hepatitis C infection relative to patients without SMI. Co-occurring substance abuse may add another layer of vulnerability to hepatitis C infection, particularly for homeless veterans.5-7
Substance abuse and dual-diagnosis treatment programs (ie, those programs that treat both substance abuse and co-occurring serious mental health problems, such as bipolar disorder, severe major depressive disorder, psychotic disorders, and posttraumatic stress disorder [PTSD]) that have integrated mental health and primary care into their treatment programs may offer a window of opportunity for risk-reducing interventions. These interventions include testing and education of patients regarding infectious diseases, such as viral hepatitis and HIV, and completion of the hepatitis A/B immunization series.
The James A. Haley Veterans’ Hospital (JAHVH) in Tampa, Florida, has demonstrated some limited success in the past with integrating a standard dosing schedule for hepatitis A/B vaccination into its substance abuse treatment program (SATP), though recent evidence points to more promising results using an accelerated regimen as indicated by a high completion rate for hepatitis B vaccination in a methadone clinic.8,9 A relatively low proportion of SATPs in the U.S. provide testing, education, or vaccination for hepatitis A and B, especially considering the public health importance of controlling these diseases in the substance abusing populations.10,11
In 1999, a primary care team was added to the alcohol and drug abuse treatment program at JAHVH.In 2005, the nurses in the program began scheduling vaccinations and screening patients for medical and psychiatric issues, pain, hypertension, diabetes, hepatitis C, alcohol use, depression, PTSD, prostate and colorectal cancers.12 Such a multidisciplinary approach provides many treatment advantages for patients and may save lives.13
Even with a multidisciplinary approach, the nurses found it difficult to provide adequate hepatitis A/B immunization within the 3- to 6-week intensive SATP, because standard immunization dosing regimens are spread over 6 months.14 As with all types of immunizations, long dosing schedules may reduce patient adherence and result in inadequate seroprotection.15 Thus, there is a need to provide a completed immunization series in a more expeditious fashion, and an accelerated dosing regimen makes that possible.15,16
Twinrix (GlaxoSmithKline, Brentford, United Kingdom) is a vaccine that provides dual immunization for hepatitis A and B. Whereas the standard vaccination schedule takes 6 months to complete, the accelerated dosing schedule can be used to complete the first 3 doses in less than a month. The accelerated dosing schedule was incorporated into the JAHVH clinic to capture as many patients as possible in the 3- to 6-week time frame: The first dose is administered and followed by a second dose 7 days later. The third dose is administered 21 to 30 days after the first dose. Twelve months after the first dose, a booster dose is given.
After the first 3 accelerated doses, > 98% of patients show a sustained immune response to hepatitis A, and > 63% demonstrate immunity to hepatitis B. If a 12-month booster injection is given, 100% of patients may receive immunity to hepatitis A and > 96% may have immunity to hepatitis B.16 Another study of the combined vaccine showed even greater seroprotection for hepatitis A and B after only 1 month, 100% and 82%, respectively.17
This JAHVH retrospective feasibility study describes a risk-reduction program for hepatitis A/B prevention that was implemented within a 3- to 4-week intensive outpatient SATP and a 6-week dual-diagnosis treatment program. The study includes the development and implementation of the program, designed to vaccinate patients using the accelerated Twinrix schedule. To ascertain the feasibility of this vaccination approach, historical medical records were used to describe and examine the vaccination initiation and follow-up rates of the treatment program participants who received the hepatitis A/B immunization series during their intensive SATP.
A retrospective review of medical records was conducted for all participants who were admitted to the intensive JAHVH SATP between October 1, 2008, and September 30, 2009. This study was reviewed and approved by the JAHVH research and development committee and its associated University of South Florida institutional review board. Informed consent to participate was not obtained, because the study was retrospective.
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