Adherence to hepatitis B virus vaccination at syringe exchange sites

COVID-19 vaccine implementation at a syringe services program: experiences of frontline staff

BACKGROUND

While people with substance use disorders, including people who inject drugs (PWID), experience increased risk for COVID-19 infection and adverse outcomes, COVID-19 vaccination rates among PWID are consistently lower than those observed in the general population. Offering COVID-19 vaccines at syringe services programs (SSPs) has been proposed as a critical strategy to increase vaccine uptake among this population. We explored the experiences of frontline staff at an SSP in Miami, Florida implementing onsite COVID-19 vaccines.

METHODS

Between June and July 2022, we conducted in-depth semi-structured interviews with 17 staff members of an SSP in Miami, Florida. Data collection and codebook thematic analysis of transcribed interviews were guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Facilitators and barriers of COVID-19 vaccine implementation at the SSP aligned with all major CFIR domains. Key facilitators included the SSP's established partnership with the local health department for vaccine distribution, its existing funding sources which could be leveraged for vaccine-related expenses, consensus among staff about the need for new strategies to increase vaccine uptake among PWID, and PWID's trust in the SSP. Major-but largely modifiable-barriers included lack of participant compensation, limited internal collaboration and communication regarding the vaccine initiative beyond implementation leads and innovation deliverers due to competing priorities and segmented roles and responsibilities, and insufficient involvement of the most participant-facing staff (i.e., the SSP's peer navigators and outreach workers).

CONCLUSIONS

Implementing onsite COVID-19 vaccines was perceived as feasible and acceptable by frontline staff at the SSP, however contextual factors impeded optimal implementation. Multilevel strategies, such as participant compensation for vaccine completion and internal educational meetings with staff to improve vaccine implementation and reach, are required. As a trusted source of preventative services for PWID, SSPs are an underutilized venue for increasing vaccine uptake among this population, and findings from this study could inform the expansion of low-barrier vaccine services at SSPs nationwide.

SARS-CoV-2 antibody prevalence, correlates, and access to harm reduction services among people who inject drugs living with and without HIV and their partners in Kenya

BACKGROUND

In sub-Saharan Africa many people who inject drugs (PWID) are living with undiagnosed or untreated HIV and experience high levels of poverty and conditions that can contribute to worse outcomes from SARS-CoV-2 infection. Identifying the burden of SARS-CoV-2 infection in marginalized populations like PWID may contribute to controlling the pandemic.

METHODS

This is a nested cross-sectional study within an ongoing cohort study that recruits PWID living with HIV and their injecting and/or sexual partners at needle and syringe program sites and methadone clinics in Kenya. Blood samples were collected from consenting participants at enrollment to determine SARS-CoV-2 antibodies using a Platellia BioRad SARS-CoV-2 total antibody enzyme-linked immunosorbent assay. Baseline data were collected on HIV status, antiretroviral therapy and methadone adherence. We used logistic regression to identify factors associated with antibody positivity and descriptive statistics to report SARS-CoV-2 antibody prevalence.

RESULTS

One thousand participants were enrolled between April and July 2021, of whom 323 (32.3%) were women and 677 (67.7%) were men. Median age of participants was 36 years (interquartile range: 30, 42). SARS-CoV-2 antibody positivity was found in 309 (30.9%) participants. Disruption in obtaining methadone service was reported by 106 (24.3%) of the participants. Men were significantly less likely than women to have SARS-CoV-2 antibodies (adjusted odds ratio [aOR] = 0.68, 95% confidence interval [CI] 0.51, 0.95; p < 0.01) Participants who reported a sexual or injecting partner diagnosed with SARS-CoV-2 were twofold more likely to have SARS-CoV-2 antibodies detected (aOR = 2.21, 95% CI 1.06, 4.58; p < 0.032). Living with HIV was not associated with presence of SARS-CoV-2 antibodies.

CONCLUSION

The seroprevalence of SARS-CoV-2 of 30.9% in this cohort suggests high transmission rates within this population. SARS-CoV-2 seroprevalence was similar for people living with and without HIV. A large portion of this population was noted to have had disruption in access to harm reduction services.

Syringe Service Program Perspectives on Barriers, Readiness, and Programmatic Needs to Support Rollout of the COVID-19 Vaccine

BACKGROUND

We explored syringe service program (SSP) perspectives on barriers, readiness, and programmatic needs to support coronavirus disease 2019 (COVID-19) vaccine uptake among people who use drugs.

METHODS

We conducted an exploratory qualitative study, leveraging an existing sample of SSPs in the United States. Semistructured, in-depth interviews were conducted with SSP staff between February and April 2021. Interviews were analyzed using a Rapid Assessment Process, an intensive, iterative process that allows for rapid analysis of time-sensitive qualitative data.

RESULTS

Twenty-seven SSPs completed a qualitative interview. Many SSP respondents discussed that COVID-19 vaccination was not a priority for their participants because of competing survival priorities, and respondents shared concerns that COVID-19 had deepened participant mistrust of health care. Most SSPs wanted to participate in COVID-19 vaccination efforts; however, they identified needed resources, including adequate space, personnel, and training, to implement successful vaccine programs.

CONCLUSIONS

Although SSPs are trusted resources for people who use drugs, many require additional structural and personnel support to address barriers to COVID-19 vaccination among their participants. Funding and supporting SSPs in the provision of COVID-19 prevention education and direct vaccine services should be a top public health priority.

Awareness, perception and utilization of a mobile health clinic by people who use drugs

INTRODUCTION

People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs.

METHODS

Semi-structured interviews were conducted with 31 PWUD - 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) - to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory.

RESULTS

Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients.

DISCUSSION

MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment.KEY MESSAGESPeople who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma.People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.

Understanding Vaccine Perceptions and Willingness to Receive COVID-19 Vaccination: Opportunities to Strengthen Public Health Responses and COVID-19 Services for People Who Use Drugs

Background: People who use drugs (PWUD) are at high risk for COVID-19 infection, morbidity, and mortality. COVID-19 vaccines are safe and effective at reducing serious illness and death from COVID-19. There are sparse data on the perceptions and willingness of PWUD to receive COVID-19 vaccination. Materials and Methods: In order to assess the perceptions of, and willingness to receive, COVID-19 vaccination among PWUD, we conducted a rapid survey-based assessment of 100 PWUD in NYC (Spring 2021) who reported not having received COVID-19 vaccination and who reported past 30-day illicit drug use. Results: More than 80% of respondents agreed that personally receiving a COVID-19 vaccine was important for the health of others in the community, and endorsing this belief was significantly associated with COVID-19 vaccine willingness reflecting a high prevalence of altruistic beliefs (p-value: 0.01). Other reported perceptions that were significantly associated with COVID-19 vaccine willingness were believing that COVID-19 vaccines are safe for PWUD and trusting COVID-19 information from their healthcare providers (p-values < 0.05). That said, 62% reported being unwilling to receive a COVID-19 vaccine, and 70−83% had concerns about general vaccine safety/efficacy. Examining pairs of questions to explore potential ambivalence between vaccine endorsement and vaccine concerns identified that 56−65% simultaneously reported vaccine safety/efficacy concerns and beliefs that vaccination was an important intervention. Of the 75 respondents who reported past 30-day use of harm reduction and/or substance use disorder (SUD) programs, nearly 90% reported these programs as trusted sources of COVID-19 information. Conclusion: Most participants reported altruistic beliefs about the role of vaccines for community health, including COVID-19 vaccines, and this altruism was associated with willingness to be vaccinated against COVID-19. These findings suggest a complex relationship between beliefs about the role of vaccination in community health and the safety/efficacy of vaccines; this ambivalence suggests that COVID-19 vaccine willingness may not be firmly fixed, indicating potential opportunities to address questions and build vaccine confidence. Harm reduction and SUD programs could be leveraged to further engage PWUD in receipt of COVID-19 information and/or vaccination. Recognizing vaccine ambivalence, emphasizing collective and individual benefits of vaccination, and messaging from trusted sources may be promising approaches to increase vaccination in this population.

Vaccination barriers and opportunities at syringe services programs in the United States, June-August 2021-A cross-sectional survey

BACKGROUND

Syringe services programs (SSPs) are an important venue for reaching people who inject drugs (PWID) to offer preventive services; however, not all SSPs offer vaccinations. We aimed to describe barriers and opportunities for SSPs to offer vaccinations.

METHODS

During June-August 2021, we conducted a descriptive, cross-sectional survey of SSP providers in the United States. SSPs were recruited from national listservs using purposive sampling to ensure geographic diversity. The survey included questions about SSP characteristics, client demographics, existing vaccination resources, resource needs, and staff perspectives on client vaccination barriers. Statistical comparisons were made using Pearson's chi-square test.

RESULTS

In total, 105 SSPs from 34 states responded to the survey; 46 SSPs (43.8%) offered on-site vaccinations. SSPs without on-site vaccinations were more likely operated by community-based organizations (81.4% vs 30.4%, p < 0.001) in urban areas (71.4% vs 40.0%, p = 0.002) than SSPs offering on-site vaccinations. The most common staffing need was for personnel licensed to administer vaccines (74/98, 75.5%). Over half of SSPs reported vaccine supply, administration supplies, storage equipment, and systems to follow-up clients for multidose series as important resource needs. The most common resource need was for reminder/recall systems for vaccines with multidose series (75/92, 81.5%). Vaccine safety concerns (92/95, 96.8%) and competing priorities (92/96, 95.8%) were the most common staff-reported client barriers to vaccinations.

CONCLUSIONS

Addressing missed opportunities for offering vaccinations to PWID who use SSPs will require increased numbers of on-site personnel licensed to administer vaccines and additional training, vaccination supplies, and storage and handling equipment.

Barriers and facilitators to use of a mobile HIV care model to re-engage and retain out-of-care people living with HIV in Atlanta, Georgia

Novel strategies to re-engage and retain people living with HIV (PLWH) who are out of care are greatly needed. While mobile clinics have been used effectively for HIV testing and linkage, evidence guiding their use in providing HIV care domestically has been limited. To guide the development of a mobile HIV clinic (MHC) model as a strategy to re-engage and retain PLWH who are out of care, we aimed to explore stakeholder perceptions of barriers and facilitators to MHC implementation and use. From June 2019-July 2020, we conducted 41 in-depth interviews with HIV clinic providers, administrators, staff, legal authorities, and community advisory board members, PLWH, AIDS service organizations and city officials in Atlanta, Georgia, and domestic and international mobile health clinics to explore barriers and facilitators to use of MHCs. Interviews were transcribed, coded and thematically analysed. Barriers raised include potential for: breach of confidentiality with resulting heightened stigmatization, fractured continuity of care, safety concerns, staffing challenges, and low community acceptance of MHC presence in their locality. Participants provided suggestions regarding appropriate exterior design, location, timing, and co-delivery of non-HIV services that could facilitate MHC acceptance and address the concerns. In identifying key barriers and facilitators to MHC use, this study informs design and implementation of an MHC as a novel strategy for re-engaging and retaining PLWH who are out of care.

Vaccine-preventable diseases other than tuberculosis, and homelessness: A scoping review of the published literature, 1980 to 2020

BACKGROUND

Homelessness may result in the breakdown of regular health services, including routine vaccination programmes. A scoping review was conducted to describe vaccine-preventable diseases (VPD) other than tuberculosis in people experiencing homelessness (PEH).

METHODS

We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We searched peer-reviewed literature published in English, French, Spanish or Portuguese reporting the outbreak of VPD or VPD prevalence in both infant and adult homeless populations published between 1980 and 2020, using PubMed/Medline, SciELO, Google Scholar, and Web of Science databases. Relevant information from the studies was charted in Microsoft Excel and results were summarised using a descriptive analytical method.

RESULTS

Eighty-one articles were included. A high prevalence of past hepatitis B virus (HBV) and hepatitis A virus (HAV) infections were observed through serosurveys, mostly in high income countries or high-middle income countries (USA, Canada, France, Iran or Brazil). Ten outbreaks of HAV infection were also reported, with lethality rates ranging from 0 to 4.8%. The studies identified numerous risk factors positively associated with HBV infection, including older age, homosexual or bisexual practice, injected drug use (IDU), and, with HAV infection including IDU, having sexual partner(s) with a history of unspecified hepatitis, insertive anal penetration, or originating from a country with a high prevalence of anti-HAV antibody. Eleven outbreaks of pneumococcal infection affecting PEH were reported in Canada and USA, with lethality rates from 0 to 15.6%. Six diphtheria outbreaks were reported. Vaccination status was rarely documented in these studies.

CONCLUSIONS

The literature suggests that homeless populations generally experience a high VPD burden suggesting the need for a national vaccination programme and planning for delivering vaccines in this population.

Trends in Prevalence of Protective Levels of Hepatitis B Surface Antibody Among Adults Aged 18-49 Years With Risk Factors for Hepatitis B Virus Infection-United States, 2003-2014

BACKGROUND

Hepatitis B virus (HBV) infection can be prevented through vaccination. However, previous data show that only about 24%-45% of US adults at high risk of HBV infection are protected. Our aims were to assess prevalence and trends in protective levels of hepatitis B surface antibody (anti-HBs) from 2003 to 2014 and explore factors associated with protection among adults at high risk.

METHODS

Data were taken from the 2003-2014 National Health and Nutrition Examination surveys. Our sample included adults aged 18-49 years who were tested for HBV and reported at least 1 of the following infection risks: history of sexually transmitted disease, sex with men (for men), infection with human immunodeficiency virus, and injection drug use. We calculated the prevalence of anti-HBs (≥10 mIU/mL), indicative of immunity from vaccination, among respondents for three 4-year time intervals (2003-2006, 2007-2010, and 2011-2014) and applied the Cochran-Mantel-Haenszel test to assess trends. Using multivariable logistic regression, we examined factors associated with positive anti-HBs serology.

RESULTS

The prevalence of positive anti-HBs serology was 23.4%. Prevalence increased from 2003-2006 (16.3%) to 2007-2010 (27.3%), but no change occurred from 2007-2010 (27.3%) to 2011-2014 (28.1%). Among factors predicting positive anti-HBs serology were young age and higher education.

CONCLUSIONS

By 2014, less than one-third of adults aged 18-49 years at risk of infection exhibited protective antibodies ≥10 mIU/mL. Because these adults account for a majority of unprotected adults, targeted intervention strategies are essential to achieve the hepatitis B elimination goal.

Epidemiological serosurvey and molecular characterization of sexually transmitted infections among 1890 sheltered homeless people in Marseille: Cross-sectional one day-surveys (2000-2015)

OBJECTIVES

We observed the prevalence and distribution of potential risk factors for sexually transmitted infections (STIs) among Marseille homeless population.

METHODS

Over the 2000-2015 period, we enrolled 1890 sheltered homeless adults and collected serum samples. Markers of hepatitis B and C viruses (HBV, HCV) and Treponema pallidum were searched using the CMIA testing. Positive HBsAg or anti-HCV samples underwent sequencing; positive anti-T. pallidum sera were subjected to the RPR test.

RESULTS

The overall prevalence of HBsAg, anti-HBs, anti-HBc, anti-HCV and anti-T. pallidum (by CMIA and RPR) was 4.1%, 22.9%, 35.5%, 5.3% and (6.8%, 1.0%), respectively. We found a significantly higher prevalence of HBsAg and anti-T. pallidum among individuals born in sub-Saharan Africa (or Asia) compared to those born in Europe. Being older (>42 years), toxicomania status, cannabis use and underweight status (compared to normal status) were independent factors associated with HCV seropositivity. Using sequencing, we obtained a substantial diversity of HBV and HCV genotypes. One HCV sequence harbouring a L31M substitution in the NS5a protein may be associated with reduced drug sensitivity.

CONCLUSIONS

The positive relationship between toxicomania and HCV suggests the need for effective prevention programmes including health education activities and addiction treatment.

Susceptibility to Hepatitis A and B Virus Among Clients at a Syringe Services Program in Philadelphia, 2018

OBJECTIVES

Although many people who use drugs meet criteria for vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV), estimates of susceptibility (ie, lack of immunity) are not well established. This study sought to identify the prevalence of and characteristics associated with HAV and HBV susceptibility among people who use drugs attending an urban syringe services program.

METHODS

We initiated this seroprevalence study in 2018 among 438 clients of a syringe services program who met study criteria, including provision of a blood specimen and a self-reported history of drug use. We assessed HAV and HBV susceptibility and infection via serological testing. We examined associations between participant characteristics and serology status by using descriptive statistics and multivariable logistic regression models.

RESULTS

Of the initial 438 clients identified, 353 (80.6%) met study criteria. Of 352 participants with conclusive HAV test results, 48.6% (n = 171) were HAV susceptible; of 337 participants with conclusive HBV test results, 32.6% (n = 110) were HBV susceptible, 24.3% (n = 82) showed evidence of past or present HBV infection, and 43.0% (n = 145) had vaccine-derived immunity. Compared with participants born before 1970, participants born during 1980-1989 had 5.90 (95% CI, 2.42-14.40) times the odds of HAV susceptibility and 0.18 (95% CI, 0.06-0.53) times the odds of HBV susceptibility, and participants born during 1990-1999 had 6.31 (95% CI, 2.34-17.00) times the odds of HAV susceptibility. Decreased odds of HAV susceptibility were associated with homelessness (adjusted odds ratio = 0.48; 95% CI, 0.28-0.82).

CONCLUSION

Despite applicable HAV and HBV vaccination recommendations, substantial gaps exist in HAV and HBV susceptibility among a population of people who use drugs. These findings highlight the need for increased HAV and HBV vaccination efforts among people who use drugs.

Strategies used by people who inject drugs to avoid stigma in healthcare settings

BACKGROUND

People who inject drugs (PWID) have limited engagement in healthcare services and report frequent experiences of stigma and mistreatment when accessing services. This paper explores the impact of stigma against injection drug use on healthcare utilization among PWID in the U.S. Northeast.

METHODS

We recruited PWID through community-based organizations (CBOs; e.g., syringe service programs). Participants completed brief surveys and semi-structured interviews lasting approximately 45 min exploring HIV risk behaviors and prevention needs. Thematic analysis examined the emergent topic of stigma experiences in relation to healthcare utilization.

RESULTS

Among 33 PWID (55% male; age range 24-62 years; 67% White; 24% Latino), most used heroin (94%) and injected at least daily (60%). Experiences of dehumanization in healthcare settings were common, with many participants perceiving that they had been treated unfairly or discriminated against due to their injection drug use. As participants anticipated this type of stigma from healthcare providers, they developed strategies to avoid it, including delaying presenting for healthcare, not disclosing drug use, downplaying pain, and seeking care elsewhere. In contrast to large institutional healthcare settings, participants described non-stigmatizing environments within CBOs, where they experienced greater acceptance, mutual respect, and stronger connections with staff.

CONCLUSIONS

Stigma against injection drug use carries important implications for PWID health. Increased provider training on addiction as a medical disorder could improve PWID healthcare experiences, and integrating health services into organizations frequented by PWID could increase utilization of health services by this population.

Predictors of hepatitis B vaccination completion among people who use drugs participating in a national program of targeted vaccination

BACKGROUND

Targeted vaccination strategies are necessary to prevent people who use drugs (PWUD) becoming infected with hepatitis B virus (HBV). The aims of this study were to provide an overview of the activities for PWUD in a decentralised vaccination program in the Netherlands and to explore the determinants associated with completing a standard hepatitis B vaccination series.

METHODS

We used data for behavioural risk groups from the register of the national vaccination program. The data concerned PWUD who were immunised against hepatitis B in the Netherlands between 2002 and 2011. A standard series of three vaccinations (at 0, 1, and 6 months) was offered at inclusion and was continued if serological markers for past or chronic HBV infection were absent. Completion of a vaccination series (at least three vaccinations, irrespective of timing) was a dependent variable in our logistic regression analysis.

RESULTS

The program reached 18,054 PWUD. Of the 15,746 participants eligible for vaccination (i.e. they were neither carriers of hepatitis B nor immune to hepatitis B), 9089 (58%) completed a series of three hepatitis B vaccinations. Factors associated with a higher completion rate of a vaccination series (p < 0.01) were: starting vaccination in the earlier years of the program, older age of PWUD, intravenous drug use, vaccine administration by addiction care centres, and flexibility in location of vaccine delivery.

CONCLUSION

Despite using a standard HBV vaccination schedule and no financial incentives, vaccination completion among PWUD was relatively high. Our results suggest that flexibility of vaccination location and administration of vaccines by healthcare workers with sustainable contact with PWUD could improve vaccination programs for this risk group.

Outcome of a hepatitis B vaccination program for clients of a drug consumption facility

BACKGROUND

Intravenous drug users (IDUs) are a risk group for hepatitis B. In Germany, the hepatitis B virus (HBV) vaccination rates in IDUs are low.

OBJECTIVES

In this study the implementation and success of HBV vaccination in a drug consumption facility (DCF) was evaluated.

STUDY DESIGN

Clients attending a DCF were asked regarding their HBV status. In case of no known HBV infection and no previous vaccination, clients interested in HBV vaccination were offered a HBV blood testing. HBV vaccination was administered to susceptible clients in months 0, 1, 6. Booster vaccinations were offered to clients without seroconversion (anti-HBs < 100 U/l).

RESULTS

193 out of 364 clients reported on a known HBV infection or immunity after vaccination. 95 (55.6%) out of 171 eligible clients underwent a HBV serology. According to HBV serology 31 (32.6%) out of 95 clients were not susceptible for vaccination (mainly due to an unknown HBV infection). 47 (73.4%) out of 64 clients susceptible were administered 3 vaccinations. 10 clients received at least one further vaccination. For those showing up for testing (36 out of 47 clients) the seroconversion rate was 69.4% (> 100 IU/l) and 83.3% (> 10 IU/l), respectively.

DISCUSSION

Only a minority of clients of a DCF was susceptible for HBV vaccination. 47 out of 64 (73.4%) susceptible clients underwent at least three administrations of the vaccine, mostly resulting in seroconversion. Even in IDUs attending a DCF, a clientele with unstable social and health conditions, HBV vaccination can be carried out successfully.

Immunogenicity and safety of high-dose hepatitis B vaccine among drug users: A randomized, open-labeled, blank-controlled trial

Due to the low uptake, adherence, and completion of vaccination among drug users, and their compromised immune responses to hepatitis B vaccination, the current practice of hepatitis B vaccination may not provide optimal protection. The aim of this study was to evaluate the immunogenicity and safety of 60 µg and 20 µg hepatitis B vaccines among drug users. A randomized, open-labeled, blank-controlled trial was conducted among drug users at 2 drug rehabilitation centers in China. The eligible participants were drug users who were serologically negative for the hepatitis B surface antigen (HBsAg) and the hepatitis B surface antibody (anti-HBs). Participants were randomized in a ratio of 1:1:1 to receive 20 µg (IM20 group) or 60 µg (IM60 group) of hepatitis B vaccine or blank control at months 0, 1, and 6, and followed at months 6, 7, and 12. Seroconversion rates of 94.7% and 92.6% were observed in IM20 and IM60 groups at month 7, and correspondingly decreased to 89.5% and 91.7% respectively at month 12. The IM60 group showed significantly higher geometric mean concentrations (GMCs) of anti-HBs (2022.5 and 676.7 mIU mL-1) than the IM20 group did (909.6 and 470.5 mIU mL-1) at months 7 and 12 (P < 0.05). No safety concerns associated with vaccination were noted. Three-dose intramuscular immunization with hepatitis B vaccines showed good immunogenicity among the drug users.

Effectiveness of pharmacy-based needle/syringe exchange programme for people who inject drugs: a systematic review and meta-analysis

AIMS

To appraise the evidence critically for effectiveness of pharmacy-based needle/syringe exchange programmes (pharmacy-based NSPs) on risk behaviours (RBs), HIV/HCV prevalence and economic outcomes among people who inject drugs (PWID).

DESIGN

Systematic review and meta-analysis.

SETTING

Primary care setting.

PARTICIPANTS

Of 1568 studies screened, 14 studies with 7035 PWID were included.

MEASURES

PubMed, Embase, Web of Sciences, CENTRAL and Cochrane review databases were searched without language restriction from their inception to 27 January 2016. All published study designs with control groups that reported the effectiveness of pharmacy-based NSP on outcomes of interest were included. Outcomes of interest are risk behaviour (RB), HIV/hepatitis C virus (HCV) prevalence and economic outcomes. The estimates of pooled effects of these outcomes were calculated as pooled odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. Heterogeneity was assessed by I² and χ² tests.

FINDINGS

Most studies (nine of 14, 64.3%) were rated as having a serious risk of bias, while 28.6 and 7.1% were rated as having a moderate risk and low risk of bias, respectively. For sharing-syringe behaviour, pharmacy-based NSPs were significantly better than no NSPs for both main (OR = 0.50, 95% CI = 0.34-0.73; I²  = 59.6%) and sensitivity analyses, excluding studies with a serious risk of bias (OR = 0.52, 95% CI = 0.32-0.84; I²  = 41.4%). For safe syringe disposal and HIV/HCV prevalence, the evidence for pharmacy-based NSPs compared with other NSP or no NSP was unclear, as few of the studies reported this and most of them had a serious risk of bias. Compared with the total life-time cost of US$55 640 for treating a person with HIV infection, the HIV prevalence among PWID has to be at least 0.8% (for pharmacy-based NSPs) or 2.1% (for other NSPs) to result in cost-savings.

CONCLUSIONS

Pharmacy-based needle/syringe exchange programmes appear to be effective for reducing risk behaviours among people who inject drugs, although their effect on HIV/HCV prevalence and economic outcomes is unclear.

Vaccination against hepatitis B virus among people who inject drugs - A 20year experience from a Swedish needle exchange program

BACKGROUND

People who inject drugs (PWID) are at particular risk of hepatitis B virus (HBV) acquisition, but often have poor access or adherence to HBV vaccination. Vaccination against HBV has been offered at a major Swedish needle exchange program (NEP) since 1994. The aim of this study was to evaluate vaccine completion and response rates, and the effect of sequential booster doses to non-responders to the standard vaccination schedule.

METHODS

PWID enrolled in the NEP 1994-2013, without serological markers for HBV at baseline (negative for HBsAg/anti-HBc/anti-HBs), were offered a three-dose standard intramuscular vaccination schedule (Engerix®-B, GSK, 20μg/mL, intended to be received at months 0, 1 and 6). Vaccination response was defined as protective levels of anti-HBs (⩾10mIU/mL). Up to three booster doses were then offered for non-responders, each followed by anti-HBs testing.

RESULTS

HBV data was available for 2352 identifiable individuals at NEP enrolment, of whom 1516 (64.5%) had no markers for previous HBV exposure or vaccination. Vaccination was initiated for 1142 (75.3%) individuals and 898 (59.2%) completed the standard vaccination schedule. Post-vaccination anti-HBs levels were available from 800 individuals, with 598 (74.8%) responding to the basic vaccination schedule. After up to three booster doses a total of 676 (84.5%) individuals achieved protective anti-HBs levels. Non-response to vaccination was associated with higher age and anti-HCV positivity (p<0.001). Eighteen incident cases of HBV infection were observed among vaccine non-responders, as well as 30 cases among those who had not completed vaccination.

CONCLUSION

We demonstrate the feasibility of including HBV vaccination in the services offered by a NEP, with completion of vaccination in a majority of HBV-susceptible PWID. The response to HBV vaccination among PWID was relatively low; however, the addition of up to three booster doses improved the response rate from 74.8 to 84.5%.

The Potential Impact of a Hepatitis C Vaccine for People Who Inject Drugs: Is a Vaccine Needed in the Age of Direct-Acting Antivirals?

BACKGROUND AND AIMS

The advent of highly effective hepatitis C (HCV) treatments has questioned the need for a vaccine to control HCV amongst people who inject drugs (PWID). However, high treatment costs and ongoing reinfection risk suggest it could still play a role. We compared the impact of HCV vaccination amongst PWID against providing HCV treatment.

METHODS

Dynamic HCV vaccination and treatment models among PWID were used to determine the vaccination and treatment rates required to reduce chronic HCV prevalence or incidence in the UK over 20 or 40 years. Projections considered a low (50% protection for 5 years), moderate (70% protection for 10 years) or high (90% protection for 20 years) efficacy vaccine. Sensitivities to various parameters were examined.

RESULTS

To halve chronic HCV prevalence over 40 years, the low, moderate and high efficacy vaccines required annual vaccination rates (coverage after 20 years) of 162 (72%), 77 (56%) and 44 (38%) per 1000 PWID, respectively. These vaccination rates were 16, 7.6 and 4.4 times greater than corresponding treatment rates. To halve prevalence over 20 years nearly doubled these vaccination rates (moderate and high efficacy vaccines only) and the vaccination-to-treatment ratio increased by 20%. For all scenarios considered, required annual vaccination rates and vaccination-to-treatment ratios were at least a third lower to reduce incidence than prevalence. Baseline HCV prevalence had little effect on the vaccine's impact on prevalence or incidence, but substantially affected the vaccination-to-treatment ratios. Behavioural risk heterogeneity only had an effect if we assumed no transitions between high and low risk states and vaccinations were targeted or if PWID were high risk for their first year.

CONCLUSIONS

Achievable coverage levels of a low efficacy prophylactic HCV vaccine could greatly reduce HCV transmission amongst PWID. Current high treatment costs ensure vaccination could still be an important intervention option.

Factors associated with hepatitis B vaccine series completion in a randomized trial for injection drug users reached through syringe exchange programs in three US cities

Background

Hepatitis B virus (HBV) is a vaccine preventable infection yet vaccination rates are low among injection drug users (IDUs) despite the high risk of infection and longstanding recommendations to promote vaccination. We sought to improve vaccination rates by reaching IDUs through syringe exchange programs (SEPs) in three U.S. cities.

Methods

IDUs were randomized in a trial comparing the standard HBV vaccination schedule (0, 1, and 6 months) to an accelerated schedule (0, 1, and 2 months) and participation data were analyzed to identify determinants of completion of the three-dose vaccine series. Independent variables explored included sociodemographics, injection and syringe access behaviors, assessment of health beliefs, HBV-associated knowledge, and personal health status.

Results

Covariates associated with completion of the three-dose vaccine series were accelerated vaccine schedule (aOR 1.92, 95% CI 1.34, 2.58, p = <0.001), older age (aOR 1.05, 95% CI 1.03, 1.07, p = <0.001), and poorer self-rated health score (aOR 1.26, 95% CI 1.05, 1.5, p = 0.02). Completion was less likely for those getting syringes from SEP customers than for SEP customers (OR 0.33, 95% CI 0.19, 0.58, p = <0.001).

Conclusions

SEPs should offer hepatitis vaccination in a manner that minimizes time between first and last visits by accelerating the dosing schedule. Public health interventions should target younger, less healthy, and non-SEP customer participants. Other health interventions at SEPs may benefit from similar approaches that reach out beyond regular SEP customers.

Latent tuberculosis infection screening in foreign-born populations: a successful mobile clinic outreach model

OBJECTIVES

We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis.

METHODS

A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011.

RESULTS

Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI.

CONCLUSIONS

Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings.

WHO guidance on the prevention of viral hepatitis B and C among people who inject drugs

Viral hepatitis B and C (HBV, HCV) disproportionately affect people who inject drugs (PWID) across the world. To date there has been little global action focusing on prevention, care and treatment of HBV and HCV among PWID. Here we report on the development process and discuss the implications of evidence informed WHO Guidelines for the Prevention of HBV and HCV in PWID. The World Health Organization (WHO) convened a Guideline Development Panel to develop recommendations on the prevention of HBV and HCV among PWID. The process followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It included the development of PICO (Population, Interventions, Comparator, Outcomes) questions and conducting systematic reviews. Quality of evidence was classified into 4 levels: high, moderate, low, and very low. In the process of moving from evidence to recommendations, the following were considered: quality of evidence, balance of benefits and harms, community values and preferences and resource use. The WHO recommendations include the following for working with PWID: offer the rapid HBV vaccination regimen; offer incentives to increase uptake and completion of the HBV vaccine schedule; needle and syringe programs should also provide low dead-space syringes for distribution; and offer peer interventions to reduce the incidence of viral hepatitis. This guideline complements other WHO documents regarding PWID, including HIV prevention initiatives such as needle and syringe programs and opioid substitution therapy. This guidance offers a first step in the prevention of HBV and HCV among PWID. However, the lack of high quality evidence in this area necessitates further research and resources for implementation.

Latent tuberculosis infection: screening and treatment in an urban setting

Despite its benefit for treating active tuberculosis, directly observed therapy (DOT) for latent tuberculosis infection (LTBI) has been largely understudied among challenging inner city populations. Utilizing questionnaire data from a comprehensive mobile healthcare clinic in New Haven, CT from 2003 to July 2011, a total of 2,523 completed tuberculin skin tests (TSTs) resulted in 356 new LTBIs. Multivariate logistic regression correlated covariates of the two outcomes (a) initiation of isoniazid preventative therapy (IPT) and (b) completion of 9 months of IPT. Of the 357 newly positive TSTs, 86.3 % (n = 308) completed screening chest radiographs (CXRs): 90.3 % (n = 278) were normal, and 0.3 % (n = 1) had active tuberculosis. Of those completing CXR screening, 44.0 % (n = 135) agreed to IPT: 69.6 % (n = 94) selected DOT, and 30.4 % (n = 41) selected self-administered therapy (SAT). Initiating IPT was correlated with undocumented status (AOR = 3.43; p < 0.001) and being born in a country of highest and third highest tuberculosis prevalence (AOR = 14.09; p = 0.017 and AOR = 2.25; p = 0.005, respectively). Those selecting DOT were more likely to be Hispanic (83.0 vs 53.7 %; p < 0.0001), undocumented (57.4 vs 41.5 %; p = 0.012), employed (p < 0.0001), uninsured (p = 0.014), and have stable housing (p = 0.002), no prior cocaine or crack use (p = 0.013) and no recent incarceration (p = 0.001). Completing 9 months of IPT was correlated with no recent incarceration (AOR 5.95; p = 0.036) and younger age (AOR 1.03; p = 0.031). SAT and DOT participants did not significantly differ for IPT duration (6.54 vs 5.68 months; p = 0.216) nor 9-month completion (59.8 vs 46.3 %; p = 0.155). In an urban mobile healthcare sample, screening completion for LTBI was high with nearly half initiating IPT. Undocumented, Hispanic immigrants from high prevalence tuberculosis countries were more likely to self-select DOT at the mobile outreach clinic, potentially because of more culturally, linguistically, and logistically accessible services and self-selection optimization phenomena. Within a diverse, urban environment, DOT and SAT IPT models for LTBI treatment resulted in similar outcomes, yet outcomes were hampered by differential measurement bias between DOT and SAT participants.

A randomized trial of a hepatitis care coordination model in methadone maintenance treatment

OBJECTIVES

We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients.

METHODS

We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services.

RESULTS

Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV-HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61).

CONCLUSIONS

Hepatitis care coordination was efficacious in increasing adherence to HAV-HBV vaccination and HCV clinical evaluation among methadone patients.

The burgeoning HIV/HCV syndemic in the urban Northeast: HCV, HIV, and HIV/HCV coinfection in an urban setting

Introduction

Despite recommendations for generation-based HCV and once lifetime HIV screening, thousands of individuals in the U.S. still remain untested and undiagnosed. This cross-sectional study examines the correlates of HCV and HIV monoinfection and HIV/HCV coinfection in an urban Northeast setting.

Methods

Utilizing an electronic database from a mobile medical clinic in New Haven, CT from January 2003 to July 2011, 8,311 individuals underwent structured health assessment and screening for HIV and HCV.

Results

HIV [N = 601 (8.0%)] and HCV [N = 753 (10.1%)] infection were identified, and 197 (26.1%) of the 753 with HCV were coinfected with HIV. Both monoinfection and coinfection status were independently correlated with crack cocaine use and increasing age. HIV/HCV coinfection was correlated with men having sex with men (MSM) (AOR = 38.53, p<0.0080), shooting gallery use (AOR = 3.06, p<0.0070), and not completing high school (AOR = 2.51, p<0.0370). HCV monoinfection correlated with health insurance (AOR = 2.16, p<0.0020), domestic violence (AOR = 1.99, p<0.0070), and being Hispanic (AOR = 2.63, p<0.0001), while HIV monoinfection correlated with having had syphilis (AOR = 2.66, p<0.0001) and being Black (AOR = 1.73, p = 0.0010).

Conclusions

Though HIV and HCV share common transmission risk behaviors, independent correlates with viral infection status in an urban Northeast setting are distinct and have important implications for surveillance, healthcare delivery, disease prevention, and clinical care.

Hepatitis B virus exposure and vaccination in a cohort of people who inject drugs: what has been the impact of targeted free vaccination?

BACKGROUND AND AIM

Forty percent of new hepatitis B virus (HBV) infections in Australia occur in people who inject drugs (PWID); long-term infection carries the risk of serious liver disease. HBV incidence among Australian PWID has not been measured since the advent of targeted (2001) and adolescent school-based "catch-up" (1998) vaccination programs. We measured HBV incidence and prevalence in a cohort of PWID in Melbourne, Australia and examined demographic and behavioral correlates of exposure and vaccination.

METHODS

Community-recruited PWID were surveyed about blood-borne virus risk behaviors and their sera tested for HBV markers approximately three-monthly over three years. Incidence was assessed using prospectively collected data. A cross-sectional design was used to examine prevalence of HBV exposure and vaccination at baseline. Poisson regression was used to identify correlates of HBV exposure and vaccination.

RESULTS

At baseline, 33.1% of participants (114/344) had been vaccinated against HBV, 40.4% (139/344) had been exposed (previously or currently infected), and 26.5% (91/344) were susceptible. HBV incidence was 15.7 per 100 person-years. Independent associations with HBV exposure included female gender, South-East Asian ethnicity, drug treatment in the past three months, injecting in prison, and prior exposure to hepatitis C virus. Independent associations with vaccination included being ≤ 25 years old, reporting HBV vaccination, and never having been to prison.

CONCLUSIONS

HBV infection continues at high incidence among Australian PWID despite the introduction of free vaccination programs. Innovative methods are needed to encourage PWID to complete HBV vaccination.

Hepatitis A/B vaccine completion among homeless adults with history of incarceration

Hepatitis B virus (HBV) vaccination rates for incarcerated adults remain low despite their high risk for infection. This study determined predictors of vaccine completion in homeless adults (N= 297) who reported histories of incarceration and who participated in one of three nurse-led hepatitis programs of different intensity. Moreover time since release from incarceration was also considered. Just over half of the former prisoners completed the vaccine series. Older age (≥40), having a partner, and chronic homelessness were associated with vaccine completion. Recent research has documented the difficulty in providing vaccine services to younger homeless persons and homeless males at risk for HBV. Additional strategies are needed to achieve HBV vaccination completion rates greater than 50% for formerly incarcerated homeless men.

Effect of age and frequency of injections on immune response to hepatitis B vaccination in drug users

Despite the high immunogenicity of the hepatitis B vaccine, evidence suggests that immunological response in drug users is impaired compared to the general population. A sample of not-in-treatment adult drug users from two communities in Houston, TX, USA, susceptible to hepatitis B virus (HBV), was sampled via outreach workers and referral methodology. Participants were randomized to either the standard multi-dose hepatitis B vaccine schedule (0, 1, and 6 months) or to an accelerated (0, 1, and 2 months) schedule. The participants were followed for 1 year. Antibody levels were measured at 2, 6 and 12 months after enrollment in order to determine the immune responses. At 12 months, cumulative adequate protective response was achieved in 65% of the HBV susceptible subgroup using both the standard and accelerated schedules. The standard group had a higher mean antibody titer (184.6 mIU/mL vs 57.6 mIU/mL). But at 6 months, seroconversion at the adequate protective response was reached by a higher proportion of participants and the mean antibody titer was also higher in the accelerated schedule group (104.8 mIU/mL vs. 64.3 mIU/mL). Multivariate analyses indicated a 63% increased risk of non-response for participants 40 years or older (p=0.046). Injecting drugs more than once a day was also highly associated with the risk of non-response (p=0.016). Conclusions from this research will guide the development of future vaccination programs that anticipate other prevalent chronic conditions, susceptibilities, and risk-taking behaviors of hard-to-reach populations.

The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: a narrative synthesis of literature

BACKGROUND

Injecting drug users (IDUs) are at increased risk of health problems ranging from injecting-related injuries to blood borne viral infections. Access to primary healthcare (PHC) is often limited for this marginalised group. Many seek care at emergency departments and some require hospital admission due to late presentation. The costs to both the individual and the health system are such that policymakers in some settings have implemented IDU-targeted PHC centres, with a number of models employed. However, there is insufficient evidence on the effectiveness of these centres to inform health service planning. A systematic review examining such interventions is not possible due to the heterogeneous nature of study designs. Nevertheless, an integrative literature review of IDU-targeted PHC may provide useful insights into the range of operational models and strategies to enhance the accessibility and acceptability of these services to the target population.

METHODS

Available literature describing the impact of IDU-targeted PHC on health outcomes, cost implications and operational challenges is reviewed. A narrative synthesis was undertaken of material sourced from relevant journal publications, grey literature and policy documents.

RESULTS

Several models have proven accessible and acceptable forms of PHC to IDUs, improving the overall healthcare utilisation and health status of this population with consequent savings to the health system due to a reduction in visits to emergency departments and tertiary hospitals.

CONCLUSIONS

Although such findings are promising, there remains a dearth of rigorous evaluations of these targeted PHC, with the public health impact of such outlets yet to be systematically documented.

A model program for hepatitis B vaccination and education of schoolchildren in rural China

OBJECTIVES

Incomplete hepatitis B virus (HBV) vaccine coverage and poor HBV-related knowledge in China leave millions of children unprotected from this life-threatening infection. To address these gaps, a pilot program for HBV education and vaccination was launched in rural China.

METHODS

In 2006, public and private organizations in the US and China collaborated to provide HBV education and vaccination to 55,000 school-age children in the remote, highly HBV-endemic area of Qinghai Province. The impact of the educational program on HBV-related knowledge was evaluated among more than 2,800 elementary school students.

RESULTS

Between September 2006 and March 2007, the three-shot hepatitis B vaccine series was administered to 54,680 students, with a completion rate of 99.4%. From low pre-existing knowledge levels, classroom educational sessions statistically significantly increased knowledge about HBV risks, symptoms, transmission, and prevention.

CONCLUSIONS

This program offers an effective and sustainable model for HBV catch-up vaccination and education that can be replicated throughout China, as well as in other underserved HBV-endemic regions, as a strategy to reduce chronic HBV infection, liver failure, and liver cancer.

Testing for HIV, sexually transmitted infections, and viral hepatitis in jails: still a missed opportunity for public health and HIV prevention

Jails provide an underutilized public health opportunity for screening for HIV, sexually transmitted infections (STIs), and viral hepatitis, and for such other infectious diseases as tuberculosis. Incarcerated individuals are more likely to be men, poor, persons of color, and at high risk for HIV. The vast majority of jails in the United States do not screen routinely for HIV or STIs, thereby missing an opportunity for HIV and STI diagnosis, treatment, and prevention. Nesting HIV testing within STI testing and treatment in conjunction with testing and treatment for other infectious diseases, as appropriate based on community prevalence, provides a public health opportunity and will enhance HIV prevention. HIV testing and linkage to care, both within corrections and in the community, comprise an important component of the "seek and treat" strategy to further prevent HIV infection. Jail-based screening of infectious diseases, especially for HIV and STIs, in conjunction with treatment and linkage to community care has thus far been a neglected component of HIV prevention among high-risk communities.

Hepatitis B vaccination among a national sample of gay and bisexual men

Less than half of gay and bisexual men indicated they had received some doses of hepatitis B virus vaccine. Hepatitis B virus vaccination was higher among men who were 18 to 29 years old (compared to those 50-59 years old), gay, or had received flu vaccine within the last year.

Hepatitis A Virus among Drug Users and the Role of Vaccination: A Review

In countries with advanced economies better health and hygiene conditions, along with the introduction, in some cases, of global vaccination, have relegated most viral hepatitis to marginal social groups and, in particular, drug users (DUs). The availability of safe and effective vaccines for hepatitis A virus (HAV) and B (HBV) may play a major role in combating this phenomenon. Despite the availability of a safe and effective vaccine for over a decade and the recommendations of international health organizations, vaccinations against HAV among DUs are not as widely known and available as are HBV vaccinations. The purpose of this review article is to present the most significant data in the literature on the prevalence of HAV among DUs and the role of targeted vaccination. To our knowledge, the present article is the first to solely deal with vaccination against HAV in DUs. Immunization after the administration of anti-HAV vaccine has been demonstrated in DUs even if they have responded significantly less than either the general population or carriers of chronic liver disease. All the vaccines were well tolerated and adherence to the vaccine schedule was good. Further studies are needed to optimize the timing and doses of vaccine to be administered to DUs, especially to assess adherence and antibody persistence. Vaccination campaigns are feasible among DUs and have proven to be highly cost-effective.

Scaling up human papillomavirus vaccination: a conceptual framework of vaccine adherence

This review article provides a conceptual framework for human papillomavirus (HPV) vaccine acceptance and adherence, with a focus on improving understanding of the sociocultural factors impacting vaccine adherence behaviour. We include a systematic review of the slowly expanding literature on HPV vaccine acceptability and uptake in developed nations, as well as the relatively few publications from poorer nations, where more than 80% of global cervical cancer related deaths occur and where the vaccine will probably have the largest impact. We suggest that this conceptual framework will not only improve our understanding of HPV vaccine uptake and adherence, but it may also guide future sociobehavioural research geared towards improving adherence to the HPV vaccine and other multi-step vaccines in a young population at risk for sexually transmissible infections.

Accelerated hepatitis B vaccination schedule among drug users: a randomized controlled trial

BACKGROUND

Hepatitis B vaccine provides a model for improving uptake and completion of multidose vaccinations in the drug-using community.

METHODS

The Drugs, AIDS, STDs, and Hepatitis (DASH) project conducted a randomized controlled trial among not-in-treatment current drug users in 2 urban neighborhoods. Neighborhoods were cluster-randomized to receive a standard behavioral intervention (which provided information on human immunodeficiency virus [HIV]) or an enhanced behavioral intervention (designed to increase acceptance of or adherence to the hepatitis B vaccination protocol). Participants within clusters were randomized to a standard vaccination schedule (vaccines at 0, 1, and 6 months) or an accelerated vaccination schedule (vaccines at 0, 1, and 2 months). The outcomes were completion of the 3-dose vaccine and seroprotection against hepatitis B virus (HBV).

RESULTS

Of participants with negative screening results for HIV and HBV, 77% accepted hepatitis B vaccination, and 75% of vaccinees received all 3 doses. Injection drug users (IDUs) on the accelerated schedule were significantly more likely to receive 3 doses (76%) than those on the standard schedule (66%; P = .04), although for drug users as a whole the corresponding adherence rates were 77% and 73%, respectively. No difference in adherence was observed between the behavioral intervention groups. Predictors of adherence were older age, African American race, stable housing, and alcohol use. Cumulative HBV seroprotection (≥10 mIU/mL) was gained within 12 months by 65% of those completing the schedule. Seroprotection at 6 months was greater for those on the accelerated schedule.

CONCLUSION

The accelerated vaccination schedule improves hepatitis B vaccination adherence among IDUs.

Sexual behavior and HBV infection among noninjecting cocaine users (NICUs)

The aim is to estimate HBV prevalence and the associated risks among noninjecting cocaine users (NICUs). In 2002-2003, a total of 824 NICUs from Buenos Aires (Argentina) and Montevideo (Uruguay) were interviewed using a structured questionnaire. Serologic tests were carried out for Human Immunodeficiency Virus (HIV), hepatitis B (HBV), syphilis, and others. The population was divided into two serologic groups: HBV-infected and seronegative group. Univariate and binary logistic model were developed. The results seem to indicate that, among NICUs, HBV is transmitted through sexual contact. Prevention measures, including vaccine, are needed in order to control and minimize risks. The study's limitations are noted.

Completion and subject loss within an intensive hepatitis vaccination intervention among homeless adults: the role of risk factors, demographics, and psychosocial variables

OBJECTIVE

Unprotected sexual behavior, needle sharing, and a prison history are major correlates of hepatitis B Virus (HBV). These risk factors are common among homeless people who also have elevated rates of HBV. We examine whether these behaviors were associated with completion or loss to follow-up of the most intensive and successful condition of a 3-arm HBV vaccination intervention. Significant results would imply that those most in need are the least compliant. Contributions of baseline demographics, physical health, psychosocial variables, and health beliefs were also assessed.

DESIGN

Three-hundred thirty-one adults from Los Angeles' Skid Row were assigned to nurse-case-managed sessions with hepatitis education, incentives, and tracking. Successive predictive structural equation models assessed the amount of variance accounted for by the risk variables, demographics, and the health-related variables.

MAIN OUTCOME MEASURES

(1) Completion of 3 injections by 6 months; and (2) loss to a 6-month follow-up questionnaire.

RESULTS

The 3 risk factors explained 2% of the variance in completion and 1% of the variance in loss. Adding the other variables increased the variance explained to 14% for completion and 13% for loss. African American ethnicity, positive coping, social support, poorer health, no prison history, and greater efficacy significantly predicted completion. White ethnicity, less social support, better health, and less intention to complete predicted participant loss.

CONCLUSION

The program was not strongly rejected differentially as a function of preexisting hepatitis B risk behaviors. Programs designed for homeless people should include malleable psychosocial and health belief model variables. These aspects of the lives of homeless people provide leverage points for future interventions.

Hepatitis vaccination of men who have sex with men at gay pride events

Prevention researchers have advocated primary prevention such as vaccination in alternative venues. However, there have been major questions about both the attendance of, and the ability to, vaccinate high-risk individuals in such settings. The current study seeks to assess the feasibility of vaccinating high-risk men who have sex with men (MSM) at Gay Pride events. The research questions are: Do gay men who are sampled at Gay Pride events engage in more or less risky behavior than gay men sampled at other venues? Do the gay men who receive hepatitis vaccinations at Gay Pride engage in more or less risky behavior than gay men at Gay Pride who do not receive hepatitis vaccination? Of the 3689 MSM that completed the Field Risk Assessment (FRA), 1095/3689 = 29.68% were recruited at either the 2006 or 2007 Long Beach, California Gay Pride events. The remaining, 2594/3689 = 70.32% were recruited at Long Beach gay bars, gay community organizations and institutions, and through street recruitment in various gay enclaves in the Long Beach area. Logistic regression analysis yielded eight factors that were associated with non-attendance of Gay Pride: Age, had sex while high in the last 12 months, had unprotected anal intercourse (UAI) in the last 12 months, had sex for drugs/money in the last 12 months, been diagnosed with a sexually transmitted infection (STI) in the last 12 months, used nitrites (poppers) in the last 12 months, and used methamphetamine in the last 12 months. Identifying as White, Asian, or African American compared to Hispanic was also associated with non-attendance. Bivariate analysis indicated that, of the MSM sampled at Gay Pride, 280/1095 = 25.57% received a hepatitis vaccination there. The MSM sampled at Gay Pride who reported engaging in UAI or having used any stimulant (cocaine, crack-cocaine, or methamphetamine) in the last 12 months were more likely to receive hepatitis vaccination on-site. The results provide evidence for the viability of successfully vaccinating high-risk MSM at Gay Pride events. However, it is vital that no-cost vaccinations are also funded in other community settings such as STI clinics, drug treatment programs, prisons, universities, and other community resource centers in order to reach those additional high-risk MSM who do not attend Gay Pride.

Predictors of HAV/HBV vaccination completion among methadone maintenance clients

This randomized, controlled study (N = 256) was conducted to compare three interventions designed to promote hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination completion among clients undergoing methadone maintenance (MM) treatment. Participants were recruited from five MM treatment sites in Southern California and randomized into three groups: Motivational Interviewing-Single (MI-Single), Motivational Interviewing-Group (MI-Group); and Nurse-Led Hepatitis Health Promotion (HHP). All were offered the three-series HAV/HBV vaccine. A total of 148 participants completed the vaccine. Groups did not differ in rate of vaccination completion (73.6%, HHP group, vs. 65% and 69% for the MI-Single and MI-Group, respectively). The equivalence of findings across groups suggests the value of including nurses with a comprehensive health focus in promoting vaccination completion.

Comparison of tuberculin skin testing reactivity in opioid-dependent patients seeking treatment with methadone versus buprenorphine: policy implications for tuberculosis screening

BACKGROUND

Buprenorphine's availability in primary care settings offers increased access to treatment and linkage to primary care for opioid-dependent patients. Currently, tuberculin skin testing (TST) is recommended for patients enrolling in methadone maintenance treatment (MMT), but not for those enrolling in buprenorphine maintenance treatment (BMT).

OBJECTIVES

To compare TST screening results in enrollees in BMT and MMT programs and assess the correlates of TST positivity among these subjects.

METHODS

A cross-sectional analysis of a retrospective cohort study was conducted to compare concurrent TST results among contemporaneously matched groups of MMT and BMT patients in the same community.

RESULTS

TST positivity was approximately 9% in both MMT and BMT settings (p = .27). Increased TST positivity was associated with being Black (AOR = 3.53, CI = 1.28-9.77), Hispanic (AOR = 3.11, CI = 1.12-8.60), and having higher education (AOR = 3.01, CI = 1.20-7.53).

CONCLUSIONS

These results confirm a similar high prevalence of TST positivity in opioid-dependent patients enrolling in MMT and BMT programs. Racial and ethnic health disparities remain associated with TST positivity, yet a relationship between higher education and tuberculosis requires further investigation.

SCIENTIFIC SIGNIFICANCE

These data suggest the importance of incorporating TST screening in emerging BMT programs as a mechanism to provide increased detection and treatment of tuberculosis infection in opioid-dependent patient populations.

The outcome of a rapid hepatitis B vaccination programme in a methadone treatment clinic

AIM

Injecting drug users are a high-risk population for hepatitis B (HBV), but are difficult to engage in vaccination programmes. This study examines the completion rates of a HBV vaccination schedule and seroconversion in a group of patients in methadone maintenance treatment.

METHODS

Patients at a public methadone maintenance programme in Sydney, Australia, were screened for viral hepatitis (hepatitis A, B and C) and offered a rapid HBV vaccination schedule (0, 1 and 2 months). Hepatitis B surface antibody (antiHBs) was retested on completion of the vaccination schedule.

RESULTS

A total of 143 patients [71.3% male, mean age 33.1 (standard deviation +/- 8.3)] enrolled in the project. Forty-nine per cent of patients were HAV antibody (Ab) positive, 81.1% hepatitis C virus (HCV) antibody (Ab) positive and 38.9% antiHBs positive. Exposure to multiple hepatitis viruses was common, with 24.5% testing positive for all three viruses. Seventy-three (83%) of the 88 antiHBs negative patients completed the vaccination schedule. Post-vaccination serology indicated a seroconversion rate of 75.4% (55 of 73) of completors, or 62.5% of eligible participants (55 of 88).

CONCLUSION

While there was a high rate of completion of the rapid vaccination schedule in this population, a moderate seroconversion rate was achieved. Further work is required to identify an optimal vaccination schedule in opioid substitution patients.

Feasibility of completing an accelerated vaccine series for homeless adults

Homeless adults are at high risk for hepatitis B virus (HBV) infection. In addition to culturally sensitive programmes designed to enhance vaccination compliance, accelerated HBV vaccination (three doses over 21 days) have also been suggested to improve compliance among high-risk groups. In this paper, we examined predictors of completers of two of three doses of a HAV/HBV vaccine series, normally delivered over a 6-month period, to simulate compliance with an accelerated series, dosed over 4 weeks. A convenience sample of 865 homeless adults was randomized into a nurse case-managed approach (NCMIT) vs standard programmes with (SIT) and without tracking (SI). Each group was assessed for completion of two of the three dose HAV/HBV vaccine series as well as the full three dose vaccine series. Sixty-eight percent of the NCMIT participants completed the three dose vaccination series at 6 months compared to 61% of SIT participants and 54% of SI participants. Eighty-one percent of the NCMIT participants completed two of the vaccinations compared to 78% of SIT participants and 73% of SI participants. The NCMIT approach resulted in greater numbers of completers of two of three doses and of the full three dose vaccine series. Predictors of completers of two doses and the full three dose vaccine series are provided. A greater number of homeless persons completed two doses across the three groups compared to the three dose vaccine series. The use of nurse case-management and tracking, coupled with an accelerated HAV/HBV vaccination schedule, may optimize vaccination compliance in homeless adults.

3 For Life: a model pilot program to prevent hepatitis B virus infection and liver cancer in Asian and Pacific Islander Americans

PURPOSE

3 For Life aims to increase hepatitis B virus (HBV) awareness and reduce the high prevalence of undiagnosed chronic HBV infection and susceptibility among Asian/Pacific Islander (API) adults.

DESIGN

This pilot program offered low-cost HBV vaccination with free HBV testing targeted primarily at foreign-born Chinese adults.

SETTING

Semimonthly screening and vaccination clinics were held in San Francisco, California, for 1 year.

SUBJECTS

A total of 1206 adults accessed the program.

INTERVENTION

Participants paid a discounted fee for a full vaccine series against HBV, hepatitis A virus (HAV), or both. Participants also provided blood samples for HBV serologic testing. Test results, recommendations, and appointment reminders were provided by mail.

MEASURES

We compared the probability of completing a recommended vaccine series by HBV serologic status and sociodemographic characteristics.

ANALYSIS

Proportions were compared using multivariate logistic regression models.

RESULTS

Nine percent of adults were chronically infected with HBV, and 53% were unprotected. In the latter group, 85% completed the HBV vaccine series. The probability of completing a recommended hepatitis vaccine series was similar across most sociodemographic groups, with slightly higher completion rates among middle-aged and Chinese participants.

CONCLUSIONS

Lessons learned from this pilot program have been used toward successful replication in other cities, demonstrating that 3 For Life is an accessible, affordable, reproducible, and sustainable model to increase HBV awareness, testing, and prevention among API adults.

Hepatitis B virus infection in US correctional facilities: a review of diagnosis, management, and public health implications

Among the blood-borne chronic viral infections, hepatitis B virus (HBV) infection is one that is not only treatable but also preventable by provision of vaccination. Despite the availability of HBV vaccine for the last 15 years, more than 1.25 million individuals in the USA have chronic HBV infection, and about 5,000 die each year from HBV-related complications. From a societal perspective, access to treatment of chronic viral infections, like HIV and viral hepatitis, is highly cost-effective and has lasting benefits by reducing risk behaviors, morbidity, mortality, as well as disease transmission in the community. Individuals in correctional facilities are specially predisposed to such chronic viral infections because of their high-risk behaviors. The explosion of incarceration in the USA over the last few decades and the disproportionate burden of morbidity and mortality from chronic infections among the incarcerated have put incredible strains on an overcrowded system that was not originally designed to provide comprehensive medical care for chronic illnesses. Recently, there has been a call to address medical care for individuals with chronic medical conditions in correctional settings, including those with infectious diseases. The economic and public health burden of chronic hepatitis B and its sequelae, including cirrhosis and hepatocellular carcinoma, is felt most prominently in managed care settings with limited budgets, like correctional facilities. Prevalence of HBV infection among the incarcerated in the USA is fivefold that of the general population. We present a review of diagnosis, prevention, and the recently streamlined treatment guidelines for management of HBV infection in correctional settings, and discuss the implications and public health impact of these measures.

Potential impact of vaccination on the hepatitis C virus epidemic in injection drug users

BACKGROUND

Hepatitis C virus (HCV) causes significant morbidity and mortality in injecting drug users (IDU) worldwide. HCV vaccine candidates have shown promise for reducing the infectivity of acute infection and averting chronic infection, yet the impact of varying levels of vaccine efficacy and vaccine delivery strategies on the HCV epidemic in IDU have not been explored.

METHODS

We utilized extensive data on injecting behavior collected in the UFO Study of young IDU in San Francisco to construct a stochastic individual-based model that reflects heterogeneous injecting risk behavior, historical HCV trends, and existing information on viral dynamics and vaccine characteristics.

RESULTS

Our modeled HCV rate closely paralleled observed HCV incidence in San Francisco, with estimated incidence of 59% per person year (ppy) early in the epidemic, and 27% ppy after risk reduction was introduced. Chronic HCV infection, the clinically relevant state of HCV infection that leads to liver disease and hepatocellular cancer, was estimated at 22% ppy (± 3%) early in the epidemic and 14% ppy (± 2%) after risk reduction was introduced. We considered several scenarios, and highlight that a vaccine with 50% to 80% efficacy targeted to high-risk or sero-negative IDU at a high vaccination rate could further reduce chronic HCV incidence in IDU to 2-7% ppy 30 years after its introduction.

CONCLUSIONS

Our results underscore the importance of further efforts to develop both HCV vaccines and optimal systems of delivery to IDU populations.

Bloodborne viral hepatitis infections among drug users: the role of vaccination

Drug use is a prevalent world-wide phenomenon and hepatitis virus infections are traditionally a major health problem among drug users (DUs). HBV and HCV, and to a lesser extent HAV, are easily transmitted through exposure to infected blood and body fluids. Viral hepatitis is not inevitable for DUs. Licensed vaccines are available for hepatitis A and hepatitis B. The purpose of this overview is to show some epidemiological data about HBV and the other blood-borne viral hepatitis among DUs and to summarize and discuss use of hepatitis vaccinations in this population. Successful vaccination campaigns among DUs are feasible and well described. We try to focus on the most significant results achieved in successful vaccination programs as reported in scientific literature. Vaccination campaigns among DUs represent a highly effective form of health education and they are cost-saving.

Preventing and controlling emerging and reemerging transmissible diseases in the homeless

Homelessness is an increasing public health problem. Because of poor living conditions and limited access to healthcare systems, homeless persons are exposed to many communicable infections. We summarize the intervention measures reported to be efficient for the control and the prevention of common transmissible infections among homeless populations. Evidence suggests that appropriate street- or shelter-based interventions for targeted populations are the most efficient methods. Depending on the populations targeted, these interventions may include education, free condom distribution, syringe and needle prescription programs, chest radiography screening for tuberculosis, directly observed therapy for tuberculosis treatment, improvement of personal clothing and bedding hygiene, and widespread use of ivermectin for scabies and body louse infestation. Systematic vaccination against hepatitis B virus, hepatitis A virus, influenza, Streptococcus pneumoniae, and diphtheria is strongly recommended. National public health programs specific to homeless populations are required.

Drug users' participation in a free hepatitis B vaccination program: demographic, behavioral, and social-cognitive determinants

The present study was conducted as an evaluation of a two-year pilot program started in 1998 in the Netherlands to provide free hepatitis B vaccination targeted at drug users (DUs). In order to identify which demographic and social-cognitive factors predict vaccination uptake, written questionnaires were distributed in three pilot regions (Amsterdam, Tiel, and Maastricht) amongst all DUs that were invited to participate in the program during a 2-month period. Vaccination behavior 2 years later was anonymously and prospectively linked to the questionnaire data, which allowed us to investigate which factors predict vaccination behavior. Of the 207 DUs eligible for vaccination (i.e., who were not immune and/or had no current infection with the virus), 93 DUs had obtained vaccination in the 2 years following the questionnaire. More than half of them (N = 50) had completed the full program (3 injections). As possible predictors of vaccination uptake, the questionnaire included constructs of the Theory of Planned Behavior as well as of the Health Belief Model. Our results show that attitude toward obtaining hepatitis B vaccination was positively associated with intention toward obtaining hepatitis B vaccination. However, perceived behavioral control was found to be the only construct related to actual vaccination uptake. None of the demographic variables were related to vaccination uptake. Our findings suggest that future interventions aimed at increasing uptake of vaccination against hepatitis B in DUs should address DUs (perceived) control concerning this behavior. The study's limitations are noted.

Preventing and controlling emerging and reemerging transmissible diseases in the homeless

Appropriate street- or shelter-based interventions for targeted populations are most effective.

Homelessness is an increasing public health problem. Because of poor living conditions and limited access to healthcare systems, homeless persons are exposed to many communicable infections. We summarize the intervention measures reported to be efficient for the control and the prevention of common transmissible infections among homeless populations. Evidence suggests that appropriate street- or shelter-based interventions for targeted populations are the most efficient methods. Depending on the populations targeted, these interventions may include education, free condom distribution, syringe and needle prescription programs, chest radiography screening for tuberculosis, directly observed therapy for tuberculosis treatment, improvement of personal clothing and bedding hygiene, and widespread use of ivermectin for scabies and body louse infestation. Systematic vaccination against hepatitis B virus, hepatitis A virus, influenza, Streptococcus pneumoniae, and diphtheria is strongly recommended. National public health programs specific to homeless populations are required.