Hepatitis A vaccination coverage in adults with chronic liver disease in primary care in England: a retrospective cohort study

Background: International guidelines recommend the administration of two doses of pre-exposure hepatitis A vaccination for people with chronic liver disease to prevent severe complications. We aimed to describe hepatitis A vaccination coverage and mortality in adults with chronic liver disease in England. Methods: We did a retrospective cohort study using routinely collected medical record data from the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RSC) primary care sentinel network. We included people aged 18 years or older who were diagnosed with chronic liver disease between Jan 1, 2012, and Dec 31, 2022. The primary outcome of interest was hepatitis A vaccination. Hepatitis A vaccination coverage was calculated using the number of vaccinated people with chronic liver disease as the numerator and the chronic liver disease population in the RSC dataset as the denominator. We compared individual characteristics by vaccination status using descriptive statistics. We used a multistate survival model to estimate the transition probabilities between four states: (1) diagnosis of chronic liver disease; (2) first hepatitis A vaccination; (3) second hepatitis A vaccination; and (4) death. Findings: 664 571 individuals aged 18 years or older with chronic liver disease were identified from the RSC sentinel network population, of whom 625 079 individuals were included in our analysis. Of 625 079 individuals with chronic liver disease, 13 875 (2·2%) had received a first hepatitis A vaccination, 3007 (0·4%) had received a second dose, 732 (5·3%) of 13 875 vaccinated individuals died, and 101 065 (16·5%) of 611 204 individuals without vaccination died during the study period. Adjusting for death as a competing risk, vaccination was more likely among younger age quintiles (hazard ratio 5·46 [95% CI 5·13–5·81]), non-smokers (1·59 [1·54–1·65]), residents of urban areas (1·28 [1·21–1·35]), individuals with higher socioeconomic status (1·06 [1·03–1·10]), and individuals with a diagnosis of metabolic dysfunction-associated steatotic liver disease (MASLD; 1·71 [1·64–1·78]). Individuals with a history of harmful alcohol use (0·36 [0·32–0·39]), type 1 diabetes (0·46 [0·36–0·57]), chronic kidney disease (0·63 [0·57–0·70]), or mental disorders (0·66 [0·64–0·69]) were less likely to be vaccinated. The lowest risk of mortality was in people with chronic liver disease of infectious or autoimmune aetiology and in people with MASLD. Interpretation: Hepatitis A vaccine uptake among people with chronic liver disease in England is low, with disparities by age, location (urban vs rural), and socioeconomic status. Steps should be taken to reduce the inequalities in vaccine administration. Funding: GlaxoSmithKline's Investigator Sponsored Studies Program.