Vaccination of high-risk groups

Selective hepatitis B vaccination is followed in the United Kingdom, rather than universal vaccination. Many other countries in Western Europe have recently introduced universal vaccination of infants (using combination vaccines) or adolescents. The UK policy is under constant review and the cost-effectiveness of such a programme is currently being reassessed.

Even if a universal policy was to be implemented in childhood, possibly with an adolescent catch up programme, it would take many years to cover all the people in high risk groups. It is therefore vital that all opportunities are taken to ensure that those at high risk are offered vaccination and that health care workers do not introduce any unnecessary barriers to vaccination of high risk individuals.

Selective hepatitis B vaccination of the following high risk groups is recommended:

• infants born to HBsAg carrier mothers should be vaccinated immediately after birth

• injecting drug users (IDUs)

• individuals who change sexual partners frequently, particularly men who have sex with men (MSM)

• male and female sex workers

• close family contacts of a case or carrier

• families adopting children from countries with high to intermediate prevalence of hepatitis B

• foster carers

• travellers to high prevalence areas

• individuals receiving regular blood or blood products (such as haemophiliacs) and their carers

• patients with chronic renal failure

• health care workers and laboratory staff

• staff and residents of residential accommodation for those with severe learning disabilities

• other occupational risk groups such as morticians and embalmers

• inmates and staff of custodial institutions

• patients with chronic liver disease.

Some of these groups are not well-defined and can be difficult to target.

Vaccination coverage of intravenous drug users has been improving, however a large proportion of at risk groups are not receiving vaccine.

Because of the high HBsAg carrier rates among ethnic minorities and the evidence that many carriers acquired infection during childhood prior to their emigration to the UK, high levels of vaccination in those at high risk will need to be maintained even if the incidence of infection in the UK declines markedly.

GP practices may choose not to provide vaccination services for those at travel or occupational risk or may impose a charge. Patients travelling can be referred to travel health clinics where appropriate. Those at occupational risk should be advised that their employers have a statutory obligation to arrange for and pay for the vaccine, if an employee is assessed to be at risk as a result of their work.

The Joint Committee on Vaccination and Immunisation is currently examining the feasibility and cost effectiveness of various additional strategies including maintaining the status quo, widening the current risk groups, or of introducing either universal infant or adolescent vaccination programmes or both.

A full discussion of hepatitis B vaccination, dosing and scheduling can be found in the updated version of the Green Book:  www.dh.gov.uk