A Quality Improvement Project to Improve Hepatitis B Vaccination Among Immunocompromised Patients With Inflammatory Bowel Disease
Background:
Immunocompromised patients with inflammatory bowel disease (IBD) often require long-term treatment with immunosuppressive medications. Chronic immunosuppression might result in vaccine preventable infections including hepatitis B infection and reactivation of previous hepatitis B infection. Hepatitis B infection can lead to liver disease, liver failure, liver cirrhosis, and liver cancer. Immunocompromised IBD patients have inadequate vaccine response and accelerated loss of antibodies against hepatitis B surface antigen warranting revaccination. Hepatitis B titers should be checked 1 to 3 months after the last dose of initial vaccination to identify non-responders and then annually to identify those with waning antibody titers. Both non-responders and those with waning antibody titers should be revaccinated. Despite society guidelines regarding screening and vaccination against hepatitis B, the hepatitis B vaccination rate is low among immunocompromised IBD patients. The reasons for low vaccination rate are lack of knowledge among providers about recommended vaccinations for IBD patients, unawareness, lack of recommendation from a reliable source such as gastroenterologists, lack of time, forgetfulness, perceived lack of benefit, and concerns about adverse effects. Studies show that educating patients and providers about the recommended vaccinations improves patient adherence and vaccination rate. The aim of this quality improvement project was to develop and implement a vaccination algorithm and to examine if hepatitis B immunity checking and vaccination recommendations had improved.
Methods:
A retrospective chart review was conducted before and after implementing the hepatitis B vaccination algorithm. Patient charts were selected based on inclusion and exclusion criteria. Inclusion criteria included patients who are 18 years and older with a diagnosis of IBD (Crohn’s disease or ulcerative colitis) taking immunosuppressive medications such as biologics, immunomodulators, or corticosteroids. Exclusion criteria included patients who are less than 18 years of age, IBD patients not taking immunosuppressive medications, general gastroenterology patients, non-IBD patients taking immunosuppressive medications, and pregnant patients. A total of 100 charts were randomly selected, 50 charts each from both periods. The chart review examined whether immunocompromised IBD patients had hepatitis B immunity laboratory test (anti-HBs or HBsAb) annually and whether providers recommended hepatitis B vaccination for non-immune immunocompromised IBD patients (HBsAb < 10 mIU/mL). The hepatitis B vaccination algorithm was developed based on available literature regarding hepatitis B vaccine immune response rate among immunocompromised IBD patients and vaccination guidelines.
Results:
Data analyses were performed using IBM SPSS Statistics Version 29 software. After implementing hepatitis B vaccine algorithm, the percentage of hepatitis B immunity lab ordered increased from 14% to 78% which was a statistically significant (χ<sup>2</sup> (1, N = 100) = 41.22, <italic>P =</italic> < .001). The percentage of not ordering labs decreased from 86% to 22%. All non-immune patients in the post-algorithm period compared to 4 out of 5 non-immune patients in the pre-algorithm period were given vaccine recommendations.
Conclusions:
Hepatitis B vaccination algorithm significantly improved hepatitis B immunity checking and vaccine recommendations by providers for immunocompromised IBD patients. Inexpensive and easily accessible educational interventions should be utilized to improve compliance with vaccinations among IBD patients.
