Hepatitis B vaccination in sexually transmitted disease (STD) clinics: a survey of STD programs

Childhood and Adolescent Vaccination in Alternative Settings

Although pediatric and adolescent vaccination rates are generally high in the United States, delayed and under-vaccination exist within certain patient populations and communities, leaving them vulnerable to vaccine-preventable diseases. One strategy for addressing this major public health concern is to offer vaccinations in nonprimary care settings such as schools, emergency rooms, hospitals, and pharmacies. This article reviews the unique advantages, challenges, and experiences regarding vaccine delivery in each alternative setting. It describes the key components that each must possess as well as other important factors to consider when assessing the ability of each to deliver vaccines to the children and adolescents they serve. It also highlights the need for sufficient funding and reimbursement for vaccine-related costs in these settings, the importance of orienting staff, providers, and practices to offering preventive care services through education and evidenced-based approaches, and the necessity of effective, efficient coordination of vaccination efforts across sites. By expanding the scope of non-primary care settings to include vaccine delivery and striving to capture all vaccination opportunities in these locations, the proportion of children and adolescents receiving on-time doses will undoubtedly increase. It is important to emphasize that these settings should not replace the medical home as the primary location for vaccination, but rather serve as a critical safety net for high-risk individuals and communities and in situations where access to traditional locations may be limited such as during the COVID-19 pandemic.

Compliance with hepatitis B vaccination among adult males with sexually transmitted infections

Background:

Sexually transmitted infections (STIs) are a diverse group of infections caused by widely differing microorganisms (viruses, protozoa, bacteria, yeasts, ectoparasites and even a nematode), with transmission from person to person by sexual contact as its common characteristic. In all societies, sexually transmitted infections rank among the most common infectious diseases. These patients are at risk for hepatitis B virus infection, but have been relatively neglected in terms of hepatitis B virus vaccination.

Objectives:

In this study, compliance with hepatitis B vaccination among adult males with sexually diseases was examined.

Patients and Methods:

In this survey, 114 males, referred to an infectious diseases clinic, were asked to complete a questionnaire evaluating their knowledge of hepatitis B vaccine, and were interviewed to assess their reasons for refusal or acceptance. Finally, SPSS (version 16) was used to perform the statistical analyses. Variables were analyzed with Chi-square tests.

Results:

The results of this study indicated that the overall hepatitis B vaccine acceptance rate was acceptably high. Among all, 53.5% correctly identified that a vaccine to prevent hepatitis B virus infection had been available, 15% had a negative opinion, and 31.5% were neutral. The rations of all three doses of vaccination were 69.3%.

Conclusions:

Among the respondents, 87% were currently married, 86.8% were currently employed, 17.5% have addiction, 34.2 % used condom, and 36.8% correctly identified hepatitis B as a sexually transmitted infection.

Promising alternative settings for HPV vaccination of US adolescents

Vaccination in alternative settings, defined here as being outside of traditional primary care, can help address the pressing public health problem of low human papillomavirus vaccine coverage among adolescents in the United States. Pharmacies are promising because they are highly accessible and have well established immunization practices. However, pharmacies currently face policy and reimbursement challenges. School-located mass vaccination programs are also promising because of their high reach and demonstrated success in providing other vaccines, but control by local policymakers and challenges in establishing community partnerships complicate widespread implementation. Health centers in schools are currently too few to greatly increase access to human papillomavirus vaccine. Specialty clinics have experience with vaccination, but the older age of their patient populations limits their reach. Future steps to making alternative settings a success include expanding their use of statewide vaccine registries and improving their coordination with primary care providers.

Hepatitis B sero-prevalence and risk behaviors among immigrant men in a population-based household survey in low-income neighborhoods of northern California

BACKGROUND

Despite an effective vaccine, 60,000 new HBV infections were reported in the US in 2004; 95% in adults. We evaluate HBV sero-prevalence, risk behaviors and self-reported vaccination among Latino immigrant, Asian immigrant and US born low income men in five northern California counties.

METHODS

Population based, cross sectional survey of HBV sero-prevalence and risk behaviors in men aged 18 to 35 years.

RESULTS

Among 1,512 men screened, Asian immigrants were most likely to have had prior HBV infection (15.1%) and chronic infection (3.8%) compared to US born (prior 5.1%, chronic 0.6%) and Latino immigrant men (prior 2.0%, chronic 0.3%.) Reported HBV vaccination was lowest for Latino immigrants (12%) compared to Asian immigrants and US born men (35% in both.) Latino immigrants reported less educational attainment, medical insurance coverage and access to a physician in the last six months.

DISCUSSION

Healthcare providers should routinely screen Asian immigrants for HBV regardless of their self reported vaccination status. Latino immigrants may comprise an important group of under-vaccinated, at risk persons in California. HBV testing and vaccination of immigrants soon after US arrival should be encouraged.

Economic benefits of hepatitis B vaccination at sexually transmitted disease clinics in the U.S

OBJECTIVE

This study assessed the long-term economic implications of a national program to vaccinate all adults treated at sexually transmitted disease (STD) clinics in a single year.

METHODS

A model was developed to track the long-term disease outcomes and costs among a hypothetical cohort of 2 million STD clinic clients accessing services in one year, using data from published sources and demonstration projects at STD clinics in San Diego (California), Illinois, and Denver (Colorado). The model estimated net economic benefits of a routine hepatitis B vaccination policy at STD clinics nationwide compared with no vaccination.

RESULTS

Without a vaccination program, an estimated 237,021 new hepatitis B virus (HBV) infections would occur over the lifetimes of the 2 million STD clinic clients seen in a single year. HBV-related medical costs and productivity losses would be $1.6 billion. In a national program for routine vaccination at STD clinics, 1.3 million adults would be expected to receive at least one vaccine dose, and an estimated 45% of the new HBV infections expected without vaccination would be prevented. The vaccination program would cost $138 million, HBV infections occurring despite the program would cost $878 million, and clients' time and travel would cost $45 million. The net economic benefit (savings) of routine vaccination would be $526 million. If the indirect costs of lost productivity due to HBV infection are not considered, routine vaccination would have a net cost of $28 million.

CONCLUSIONS

Estimates from this model suggest a national program for routine hepatitis B vaccination of adults at STD clinics would be a cost saving to society.

The effect of vaccinated children on increased hepatitis B immunization among high-risk adults

OBJECTIVES

We sought to examine trends in hepatitis B virus (HBV) vaccination among high-risk adults and assess the potential effect vaccinated adolescents have on these trends as they age.

METHODS

We used data from the National Health Interview Survey 2000, 2002, and 2004 to examine trends in HBV vaccination among high-risk adults aged 18 to 49 years and in age subgroups (18-29, 30-39, and 40-49 years). We investigated temporal differences in vaccination rates for the 18- to 29-year-old cohort with model-based linear contrasts constructed from a logistic regression model with age and survey year as predictors.

RESULTS

There was a significant increasing trend in vaccination prevalence across the 3 survey years (32.6%, 35.3%, and 41.4%; trend test, P=.001). We found that respondents aged 18 to 29 years were more likely to be vaccinated in 2004 than in 2000, after adjusting for relevant confounders (odds ratio=1.73; 95% confidence interval=1.14, 2.6); there was no significant increase in vaccination for the other cohorts.

CONCLUSIONS

A cohort effect, in which successfully vaccinated adolescents have reached young adulthood, contributes significantly to recent trends showing improved HBV vaccination among high-risk adults.

How effectively can health care settings beyond the traditional medical home provide vaccines to adolescents?

OBJECTIVES

Our goal was to evaluate the capacity of various health care settings to supplement the activities of the traditional medical home by delivering vaccines to adolescents.

METHODS

A group of experts in the fields of adolescent-immunization delivery and the provision of preventive care in various health care settings summarized the available literature, considered setting-specific factors, and assessed the ability of various health care settings beyond the traditional medical home to conform to the immunization quality standards set by the National Vaccine Advisory Committee, report vaccination information for the quantitative assessment of vaccine-coverage rates, be likely to offer vaccines to adolescents, and be viewed by adolescents as acceptable sites for receiving vaccinations.

RESULTS

Seven candidate settings were evaluated: pharmacies, obstetrics-gynecology practices, sexually transmitted disease clinics, hospital emergency departments, family planning clinics, teen clinics, and local public health department immunization clinics. The panel concluded that all could safely provide vaccinations to adolescents but that vaccination efforts at some of the settings could potentially have a markedly greater impact on overall adolescent-immunization rates than could those at other settings. In addition, for adolescent-vaccination services to be practical, candidate settings need to have a clear interest in providing them. Conditional on that, several issues need to be addressed: (1) funding; (2) orienting facilities to provide preventive care services; (3) enhancing access to immunization registries; and (4) clarifying issues related to immunization consent.

CONCLUSIONS

With supporting health policy, health education, and communication, health care settings beyond the traditional medical home have the potential to effectively augment the vaccination efforts of more traditional settings to deliver vaccines to adolescents. These health care settings may be particularly well suited to reach adolescents who lack access to traditional sources of preventive medical care or receive fragmented medical care.

Integrating viral hepatitis prevention into STD clinics in Illinois (excluding Chicago), 1999-2005

Hepatitis B vaccination is recommended for all clients of sexually transmitted disease (STD) clinics. Hepatitis A vaccination and hepatitis C testing are recommended for STD clinic clients who report specific risks for those viruses. In 1999, the Illinois Department of Public Health began working with local health departments in Illinois (excluding Chicago) to introduce hepatitis B testing and vaccination in public STD clinics. Hepatitis A vaccination and hepatitis C counseling and testing were introduced in 2001. Illinois state funding has covered more than one-third of the costs of offering these integrated viral hepatitis services to STD clients. Hepatitis A and B vaccination and hepatitis C counseling and testing are now the standard of care in almost all (35 of 41) Illinois public STD clinics (excluding Chicago). In 2005, 29.4% of STD client visits included a hepatitis B vaccination. In public STD clinics in Illinois, hepatitis A and B vaccinations and hepatitis C counseling and testing have increased from essentially no activity in 1999 to substantial levels of service in 2005.

Prevalence and factors associated with self-reported vaccination rates among US adults at high risk of vaccine-preventable hepatitis

BACKGROUND

Despite a routine vaccination for preventing HAV and HBV in young age groups during the past decade, adults at high risk of hepatitis are not reached effectively by vaccination programs. This study sought to estimate the prevalence of adults at higher risk of vaccine-preventable hepatitis (hepatitis A virus (HAV) and hepatitis B virus (HBV)) in the US and their vaccination rates. Also, the association between vaccination rates and selected demographic, socio-economic characteristics and comorbidities was investigated.

METHODS

Four years, 1999-2002, of publicly available National Health and Nutrition Examination Survey (NHANES) data were utilized. Survey participants aged 20-59 years were selected. A survey participant was considered at higher risk when their situation and/or behavior placed them at a greater risk of contracting hepatitis as identified by the Centers for Disease Control and Prevention. All prevalence estimates were weighted to represent the total US population using 4-year interview and examination weights. Logistic regression was utilized to identify factors associated with vaccination rates.

RESULTS

The study included 6237 survey participants who represent over 153 million adults age 20-59 years. Of these adults, 8.0%, 12.3% and 1.4% were at higher risk of HAV, HBV or both respectively. The self-reported vaccination rates among the higher risk population groups were 13%, 23.6% and 13.4% respectively. The most prevalent risk groups were persons with sexually transmitted diseases and persons using noninjection illegal drugs. Within the higher risk population, being single, male, aged 50-59 years and uninsured were all significantly (p < 0.05) less likely to be vaccinated than their counterparts.

LIMITATIONS

The results of this study should be interpreted within the context of the following limitations: (1) the potential biases associated with participants' self-reported vaccination rates; (2) institutionalized US population with high prevalence rates of hepatitis infection are not included in the NHANES data.

CONCLUSIONS

Among the population identified at higher risk of vaccine-preventable hepatitis (HAV, HBV or both), only a small proportion of this group had evidence of hepatitis vaccination.

Cost effectiveness of hepatitis B vaccination at HIV counseling and testing sites

BACKGROUND

Despite recent significant achievements in controlling hepatitis B virus (HBV) infection, immunizing high-risk groups against the disease remains a public health challenge in the United States. The aims of this article are to evaluate the projected cost effectiveness of hepatitis B vaccination of adults attending two major types of publicly funded HIV counseling and testing sites (CTSs)-freestanding HIV CTSs and sexually transmitted disease (STD) clinics, and to compare the cost-effectiveness of alternative vaccination and testing strategies in different subgroups in this population.

METHODS

A decision model was developed to determine the economic and clinical consequences, from a societal perspective, of the following strategies in two hypothetical cohorts of 100,000 adults attending each type of site: (1) routine vaccination without screening, (2) screening for antibody to hepatitis B core antigen with an initial vaccine dose during the first visit, (3) screening and vaccination based on screening results, and (4) no intervention. Life expectancy, expected quality-adjusted life years (QALYs), and medical care costs were estimated for each strategy and at each site.

RESULTS

Routine vaccination was both more effective and more cost-effective than either screening strategy; under base-case assumptions, routine vaccination would cost $4400 both per QALY and per life year saved. Results for STD clinics were very similar in magnitude to those for freestanding CTSs. Results were most sensitive to clients' time and travel costs for return visits and the time-discount rate.

CONCLUSIONS

Routine provision of hepatitis B vaccine at major HIV CTSs would be a highly effective and cost-effective approach to preventing hepatitis B among high-risk adults in the United States.

Hepatitis A and B immunization in persons being evaluated for sexually transmitted diseases

Sexual transmission accounts for the majority of hepatitis B virus (HBV) infections in industrialized countries. Hepatitis A virus (HAV) can be transmitted by sexual practices that involve fecal-oral exposure. Both infections are disproportionately frequent in men who have sex with men (MSM). Routine immunization against HBV is recommended for MSM and for persons being evaluated or treated for sexually transmitted diseases (STDs), and HAV immunization is advised for MSM and for other persons at risk who are commonly seen in STD care settings, such as users of illegal drugs. However, numerous attitudinal and structural barriers interfere with routine immunization in persons at risk for sexual acquisition of HAV and HBV. Substantial success has been documented in vaccinating persons at risk in public STD clinics and other settings; however, at a national level, efforts to achieve desired immunization rates have largely failed. Until universal childhood immunization produces a largely immune adult population, the universal vaccination of adults-as a supplement to the current risk-based approaches-may be worthwhile to achieve immunization of persons at risk for sexual transmission of HBV.

Sexual transmission of hepatitis B

PURPOSE OF REVIEW

Hepatitis B virus infection is prevalent worldwide and is a significant cause of morbidity and mortality particularly in Asia. Adults chronically infected with hepatitis B virus remain a significant potential source of sexually transmitted hepatitis B. The purpose of this article is to review the recent literature relating to hepatitis B virus transmission with particular emphasis on sexual transmission and efforts to prevent spread.

RECENT FINDINGS

The introduction of hepatitis B virus vaccine and the implementation of universal childhood vaccination for hepatitis B in some countries have led to a dramatic reduction in the number of children with chronic hepatitis B. However, recent reports suggest that we are not as successful in preventing infection by sexual transmission. It is clear that sexual transmission of hepatitis B virus is still widespread and is a major problem in certain high-risk groups such as men who have sex with men, intravenous drug users, prisoners and sex workers. Significant problems remain with respect to education and vaccination within these groups.

SUMMARY

Hepatitis B virus remains a major health burden but it is preventable by education and vaccination. Greater resources are required to expand vaccination to the at-risk, sexually active adult populations if the World Health Organization ideal of hepatitis B virus eradication is to be realized and the burden of hepatitis B virus-related morbidity and mortality contained.

Predictors of acceptance of hepatitis B vaccination in an urban sexually transmitted diseases clinic

BACKGROUND

Individuals who use sexually transmitted disease (STD) clinics are at high risk for hepatitis B virus (HBV). While HBV vaccine is frequently offered to clients in this setting, reported vaccination rates are low. More information is needed about HBV vaccine knowledge, attitudes, beliefs, and behavior among high risk populations. The current study assesses these issues at an urban STD clinic.

METHODS

A survey assessing knowledge, attitudes, and beliefs concerning HBV vaccine was administered to individuals seeking services at an STD clinic before seeing the physician. Immediately after the clinical visit these individuals were interviewed and asked whether they had accepted vaccination and their reasons for acceptance or rejection.

RESULTS

Fifty percent of unvaccinated study subjects elected to receive an HBV vaccine dose at the current visit. Significant predictors in a multiple logistic regression model for choosing to be vaccinated were: having a vaccinated acquaintance, perceived risk of disease, perceived healthfulness of vaccine, and clinician's recommendation. Knowledge regarding hepatitis B risks and outcomes was not related to vaccine choices. Patients expressed concern about vaccine safety and provider motivation.

CONCLUSIONS

The role of acquaintances and the physician are central to the decision to be vaccinated, as are risk perception and familiarity with the vaccine. Mistrust of the medical establishment and of vaccines is a barrier to acceptance of HBV vaccine.

Hepatitis B virus infection and vaccination among young injection and non-injection drug users: missed opportunities to prevent infection

INTRODUCTION

We examined correlates of HBV infection and vaccination and the missed vaccination opportunities among young injection drug users (IDUs) and non-injection drug users (NIDUs).

METHODS

Two hundred IDUs and 124 NIDUs aged 15-30 years were studied. Demographics, drug use and sexual behaviors, and health and incarceration history data were collected. Serology was conducted for antibodies to HBV-core antigen (anti-HBc) and HBV-surface antigen (anti-HBs). Presence of anti-HBc indicated past HBV infection; presence of anti-HBs alone indicated past vaccination.

RESULTS

More IDUs had been infected with HBV in the past than NIDUs (37% versus 19%, P = 0.001). Among male and female IDUs, injection drug use behaviors were significantly associated with past infection. For female IDUs, being African-American and trading sex were also associated with previous infection. Among NIDUs, being female and longer time since sexual debut were associated with past infection. Overall, 11% were vaccinated (10% IDU versus 14% NIDU, P = 0.30). Younger age and drug treatment history were associated with vaccination. Most susceptibles (84%) experienced at least one missed opportunity for vaccination.

CONCLUSION

Young drug users remain at high risk for HBV infection. Vaccination rates remain low despite multiple opportunities for vaccination. An integrated HBV immunization effort should be coordinated among venues frequented by young drug users.

Hepatitis B Virus Infection Risk Factors and Immunity Among Sexually Transmitted Disease Clinic Clients

BACKGROUND AND OBJECTIVES

Hepatitis B virus (HBV) infection is a sexually transmitted infection that can be prevented with hepatitis B vaccination.

GOAL

The goal was to determine prevalence and risk factors for HBV infection and immunity among sexually transmitted disease (STD) clinic clients.

STUDY DESIGN

In this cross-sectional study, consenting adult STD clinic clients were interviewed regarding HBV risk factors and vaccination history, and blood was drawn for HBV serologic testing.

RESULTS

Of the 682 participants, 154 (22.6%) had antibody to hepatitis B core antigen, indicating previous infection, and 64 (9.4%) had only antibody to hepatitis B surface antigen, indicating immunity as a result of hepatitis B vaccination. Only 130 (19.1%) of all participants reported receiving at least one dose of hepatitis B vaccine.

CONCLUSION

The majority of clients were susceptible to HBV, were at high risk for HBV infection, and would benefit from hepatitis B vaccination.

Cost-Effectiveness of Hepatitis A/B Vaccine versus Hepatitis B Vaccine in Public Sexually Transmitted Disease Clinics

BACKGROUND

Many patients seen at U.S. sexually transmitted disease (STD) clinics are offered hepatitis B vaccination. Substituting hepatitis A/B vaccine would provide additional protection but increase costs.

GOAL

The goal was to estimate the cost effectiveness of hepatitis A/B versus B vaccination for 1,000,000 public STD clinic attenders.

STUDY DESIGN

A Markov model of hepatitis A outcomes was developed using published literature, U.S. government databases, and expert panel opinion. Added vaccination costs were compared with savings from reduced hepatitis A treatment. Net costs were compared with life-years saved and quality-adjusted life-years (QALYs) gained.

RESULTS

Substituting hepatitis A/B vaccine would prevent 2263 overt hepatitis A infections, 292 hospitalizations, 8 premature deaths, and the loss of 281 QALYs. Net health system costs would be $20,892 per life-year saved, or $13,397 per QALY gained.

CONCLUSION

Substituting hepatitis A/B for hepatitis B vaccine would reduce morbidity and mortality in a cost-effective manner.

Hepatitis A and B vaccination in a sexually transmitted disease clinic for men who have sex with men

BACKGROUND

Sexually transmitted disease clinics can deliver hepatitis vaccines to men who have sex with men, but have been reluctant to do so because of perceived low vaccination completion rates.

GOAL

The goal was to evaluate hepatitis A and B vaccination eligibility, acceptance, and completion and the effectiveness of reminder/recall in a sexually transmitted disease clinic serving men who have sex with men.

DESIGN

Clients self-reported their eligibility for free vaccine. Consenting clients who accepted a first dose of vaccine were systematically assigned to receive telephone reminder/recall or standard follow-up.

RESULTS

Of 1203 clients, 71.8% were eligible for both vaccines; 62.6% of those eligible accepted both. Reminder/recall was associated with increased receipt of the second dose of hepatitis B vaccine (86.7% versus 80.4% among intervention and control groups, respectively), but not with completion of both vaccine series (55.9% versus 58.8%).

CONCLUSION

The majority of clients were eligible for both hepatitis vaccines, and most eligible clients accepted a first dose of both vaccines. Reminder/recall, as delivered at this clinic, failed to increase the proportion of clients who received all vaccine doses. New delivery mechanisms should be explored.

Factors affecting hepatitis vaccination refusal at a sexually transmitted disease clinic among men who have sex with men

BACKGROUND

Men who have sex with men (MSM) attending sexually transmitted disease (STD) clinics should be considered candidates for hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination. However, vaccination rates in STD clinics remain less than optimal.

GOAL

The goal was to identify factors that affect HAV and HBV vaccination refusals.

STUDY DESIGN

A survey was administered to MSM eligible for the vaccinations attending an STD clinic. Vaccines were offered at the end of the clinic visit.

RESULTS

Rates of refusal of HAV (RefuseA) and HBV (RefuseB) vaccinations were 36% and 38%. Health motivation was associated with acceptance, while clinical barriers such as "want to test first for immunity," and "want to talk to own doctor first" were associated with refusal. "Not enough time this evening" was most strongly predictive of refusal, relative to strongly disagree (risk ratios [RRstrongly agree] and 95% confidence limits for RefuseA and RefuseB were 2.69 [1.43, 5.05] and 2.02 [1.05, 3.87], respectively).

CONCLUSIONS

To increase acceptance, patients less health-motivated should be identified for prevaccination counseling. Some perceived barriers such as time may be a partial excuse; staff should identify and address other perceptions that may be influencing patients' decisions.