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We were highly interested by the results obtained by Sethi et al. on hepatitis B vaccination for male sex workers. As the authors report, the national strategy for Sexual Health and HIV in England set the target uptake of the third dose of hepatitis B vaccine in susceptible heterosexual and bisexual men attending genitourinary medicine clinics at 50% by the end of 2004 a...
We were highly interested by the results obtained by Sethi et al. on hepatitis B vaccination for male sex workers. As the authors report, the national strategy for Sexual Health and HIV in England set the target uptake of the third dose of hepatitis B vaccine in susceptible heterosexual and bisexual men attending genitourinary medicine clinics at 50% by the end of 2004 and 70% by the end of 2006. In this study 60% of the eligible men received three vaccine doses; this is a stimulating result, obtained by a focused approach of the target group.
However, we cannot agree with the authors’ definition of complete vaccination. Three doses of hepatitis B vaccine were offered according to a 0,1,2 months schedule. According to the literature on hepatitis B vaccination schedules, a full vaccination course against hepatitis B consists of a an initial series of 2 (0,1 months) or 3 doses (0,1,2 months, or 0,7,21 days in an accelerated schedule), followed by a completing dose given several months thereafter. According to the Centers for Disease Control and Prevention, the usual schedule for adolescents and adults is 2 doses separated by no less than 4 weeks, and a third dose 4-6 months after the second dose; the first and third doses should be separated by no less than 16 weeks; doses given at less than these minimum intervals should not be counted as part of the vaccination series.
Such standard 0,1,6 month, or 0,1,4 month or 0,2,4 month schedules have shown to confer very good protection (90-95% >10 IU/L), comparable to that obtained with a 0,1,2,12 month schedule. In addition, lifelong protection is assumed if at least 10 IU/L is obtained, measured 1 to 3 months after a full hepatitis B vaccination course in healthy individuals. Therefore, no conclusions on long term protection can be drawn from anti-HBs values of 10 IU/L or more after 3 doses offered according a 0,1,2 months schedule.
We agree that a 0,1,2,12 month schedule is hard to implement in this mobile at risk population, and many health services have chosen to offer a 0,1,6 months or even the shortest course 0,1,4 months in hard to reach risk groups.[6-8] Therefore we would recommend to implement the shortest possible full vaccination schedules, in particular in this at-risk population. We are convinced that the focused approach presented in this paper could result in a comparably high uptake of a third dose 4 or 6 months after the first one, without jeopardising the long-term benefits of hepatitis B vaccination.
1. Sethi G, Holden BM, Greene L, et al. Hepatitis B vaccination for male sex workers: the experience of a specialist GUM service. Sex Transm Infect 2006;82:84-85.
2. Department of Health. National strategy for sexual health and HIV. London, DoH, 2001 (www.dh.gov.uk)
3. Centers for Disease Control and Prevention. Epidemiology & Prevention of Vaccine-Preventable Diseases (The Pink Book) 9th Edition, January 2006. Chapter 15, p.221. Available online from www.cdc.gov/nip/publications/pink/def_pink_full.htm4. Mast E, Mahoney F, Kane MA, Margolis HS. Hepatitis B vaccine. In: Plotkin SA and Orenstein WA, editors. Vaccines. Elsevier Inc., USA. 4th Edition, 2004:p.299-337.
5. Kane M, Banatvala J, Van Damme P, et al. Are booster immunisations needed for lifelong hepatitis B immunity? European Consensus Group on Hepatitis B Immunity. Lancet 2000;355:561-565.
6. Jilg W. Vaccination against Hepatitis B: Comparison of three different vaccination schedules. Journal of Infectious Diseases 1989;160:766-69.
7. Van Ardenne N, Roelofs I, Leuridan E, et al. Audit on offering and accepting hepatitis B vaccine by sex workers. Intern J STD AIDS 2004;15:493-494.
8. Jaleel H, Allan PS, Huengsberg M, Natin D. Offering the vaccine and accepting it: an audit of hepatitis B vaccination in West Midlands region. Intern J STD AIDS 2003;14:632-635.