Vaccines for preventing hepatitis B in health-care workers

Agreement between reported use of interventions for liver diseases and research evidence in Cochrane systematic reviews

BACKGROUND/AIMS

This study evaluates the agreement between reported use of interventions for patients with liver diseases and research evidence in Cochrane systematic reviews.

METHODS

In July 2002, the Cochrane Hepato-Biliary Group had completed 28 systematic reviews on 36 interventions that were available in Denmark. Based on the reviews, three interventions (n-acetylcysteine for paracetamol overdose, terlipressin for bleeding oesophageal varices, and antibiotics for patients with cirrhosis and gastrointestinal bleeding) with significant beneficial effects on clinical outcomes were classified as 'evidence-based', whereas 19 were classified as 'possibly evidence-based', and 14 as 'not evidence-based'. Questionnaires on reported use and perceived intervention effects were mailed to 108 physicians practising in Danish hospitals. Sixty-six returned their questionnaire.

RESULTS

The proportion of physicians who reported that they never used the three evidence-based interventions varied considerably (2, 62, and 57%, respectively). The perceived intervention effect, duration of clinical experience, employment as head of department, and university hospital employment were significant predictors of more frequent use of evidence-based interventions. Physicians also reported that they used the interventions that were not evidence-based more often if they were employed at a university hospital.

CONCLUSIONS

Considerable disagreements between reported use and research evidence were identified. Additional research on methods to introduce evidence-based medicine in practice seems warranted.

Vaccines for preventing hepatitis B in health-care workers

BACKGROUND

Hepatitis B virus (HBV) causes acute and chronic liver diseases. Hepatitis B vaccination is recommended for health-care workers.

OBJECTIVES

To assess the beneficial and harmful effects of hepatitis B vaccination in health-care workers.

SEARCH STRATEGY

We searched the trial registers of The Cochrane Hepato-Biliary Group, The Cochrane Library, MEDLINE, and EMBASE to February 2003.

SELECTION CRITERIA

Randomised trials comparing any dose, injection route, injection site, or schedule of hepatitis B plasma-derived vaccines (PDV) or recombinant vaccines (RV) versus placebo, no intervention, or another hepatitis B vaccine in health-care workers.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted the data independently. The reviewers assessed the methodological quality of the trials regarding generation of the allocation sequence, allocation concealment, double blinding, and follow-up. The results were presented as relative risk (RR) with 95% confidence intervals (CI).

MAIN RESULTS

We identified 21 randomised trials, all with one or more methodological weaknesses. Four trials demonstrated that PDV versus placebo significantly decreased hepatitis B events at maximum follow-up (RR 0.51, 95% CI 0.35 to 0.73). RV did not differ significantly from PDV in eliciting a protective hepatitis B surface antibody (anti-HBs) level in two trials. Both vaccines were well tolerated. Low-dose vaccine (1 or 2 microg) by the intradermal route resulted in significantly more participants without protective anti-HBs level compared with high-dose (10 or 20 microg) by the intramuscular route (RR 1.41, 95% CI 1.13 to 1.76). The intradermal route caused significantly more local adverse events, while the intramuscular route caused significantly more systemic adverse events. The gluteal injection produced significantly more participants without protective anti-HBs level than the deltoid injection. The prevalence of anti-HBs seroconversion by rapid vaccination (0, 1, and 2 months) was significantly lower than that by standard vaccination (0, 1, and 6 months). Booster vaccinations with different RV doses (2.5, 5, 10, 20, or 40 microg) produced similar prevalence of anti-HBs seroconversion in three trials assessing participants who did not respond to previous HBV vaccination.

AUTHORS' CONCLUSIONS

PDV significantly prevents hepatitis B events. RV seems to be able to elicit similar protective anti-HBs levels. The intramuscular route with 20 microg RV was significantly more effective compared with the intradermal route with 2 microg RV as was the standard schedule compared with a rapid schedule and deltoid intramuscular injection compared with the gluteal intramuscular injection. It is unclear if booster vaccination of non-responders offers higher anti-HBs seroconversion and hepatitis B vaccine prevents the infection of hepatitis B mutants in health-care workers.