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

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Sero-prevalence of hepatitis B virus and compliance with hepatitis B vaccination schedules among outpatient clinic attendees in Nairobi

BACKGROUND

Hepatitis B is becoming a growing public health problem in Kenya. To combat the threat, HBV vaccination should be recommended, particularly for individuals who are not covered by the national immunization program. Vaccination provides sero-protection rates approaching 95% among healthy adults after completing the three-dose vaccination course, but decreases to 87% among those who receive only two doses, emphasizing the importance of completing the three-dose vaccination course. However, data on adult adherence to HBV multi-dose vaccines in Sub-Saharan Africa are limited, despite the fact that this information is critical for prevention. As a result, more research on HBV vaccine dose completion is required. The purpose of this study is to estimate the prevalence of hepatitis B virus infection among out-patient clinic attendees in Nairobi, Kenya, as well as to identify beneficiaries of free vaccination and barriers to completing the recommended vaccine doses.

METHODS

Between July 30th and September 30th, 2015, 2644 outpatient clinic attendees aged ≥ 4 were recruited from three hospitals in Nairobi County, Kenya: Mama Lucy, Riruta, and Loco. Self-administered questionnaires were used to collect socio-demographic information, and blood samples were tested for hepatitis B surface antigen (HBsAg) using the KEMRI HEPCELL Rapid® (Hepatitis B Detection kit) test kit. Individuals who tested negative for HBsAg were given a free course of three doses of HBV vaccine. The vaccination register provided information on the number of doses administered.

RESULTS

The average age of the study population was 31.4 years (range: 4-66), with females accounting for 59.2%. 1.82% (48/2644) of the participants tested positive for HBsAg. Among the 2596 individuals eligible for vaccination, 66% (1720/2596) received at least one dose, and 51.8% (1345/2596) received all three doses. Vaccination acceptance increased with age, with older patients more likely to return for subsequent dose (OR>1 for second and third dose). Unavailability and failure to contact client were cited as significant (p<0.0001) barrier to vaccination completion by 53.7% (666/1226, 95% CI 0.5-0.6) and 37% (454/1226, 95% CI 0.3-0.4) of respondents respectively.

CONCLUSION

The prevalence of HBV infection among outpatient clinic attendees highlights the importance of expanding HBV immunization programs in Kenya. However, given the low vaccination completion rate, there is a need for public awareness of the vaccine's importance in preventing HBV and HBV-related complications.

Vaccine acceptability, uptake and completion amongst men who have sex with men: A systematic review, meta-analysis and theoretical framework

BACKGROUND

Due to an increased risk of sexually transmitted infections (STIs), gay, bisexual and other men who have sex with men (MSM) have been recommended to receive vaccinations against human papillomavirus, meningitis C and hepatitis A/B. This review aimed to compare the rates of vaccine acceptability, uptake and completion, and to identify determinants of vaccine outcomes specific to MSM to inform a theoretical framework.

METHODS

In January 2020 four databases were explored to identify vaccination behaviours and associated factors among MSM. A narrative systematic review and meta-analysis were performed. Data were synthesised for theoretical modelling.

RESULTS

Seventy-eight studies, mostly from the USA, were included. The average vaccine acceptability was 63% (median = 72%, range: 30%-97%), vaccine uptake 45% (median = 42%, range: 5%-100%) and vaccine completion 47% (median = 45%, range: 12%-89%). Six categories of factors associated with vaccination acceptability, uptake and completion were conceptualised: Individual (e.g., demographic and psychosocial); Interpersonal (e.g., peer education); Healthcare provider (e.g., vaccine recommendation); Organisational and practice setting (e.g., routine collection of patient sexual orientation information that is integrated into a clinical decision support system); Community environment (e.g., targeted health promotion campaigns); and National, state and local policy environment (e.g., public health guidelines targeting MSM).

CONCLUSION

Despite overall high levels of acceptability, uptake and completion rates were below targets predicted by cost-effectiveness modelling across all recommended vaccines. These parameters may need to be adjusted for more precise estimations of cost-effectiveness. Addressing the multiple levels of determinants, as outlined in our theoretical framework, will help guide interventions to increase vaccine completion among MSM.

Improving the vaccination status of liver transplant patients: Effectiveness of personally addressing patients and written recommendations to family physicians after 3 years

Background

After documenting insufficient vaccinations in 444 liver transplant (LT) patients, we investigated the effects of a combined strategy (addressing both patients and primary care physicians) on immunization prevalences after a 3‐year follow‐up.

Methods

The primary care physicians of all adult LT patients from a university center received a written recommendation addressing immunization needs. Patients were asked for their vaccination documents by phone. Changes in immunization rates for vaccine‐preventable diseases after the intervention were calculated based on patients’ immunization documents from 2014‐2016.

Results

The study cohort consisted of 401 patients. Prevalence rates for all vaccinations improved during the intervention period compared to the baseline study: tetanus from 88.3% to 92.8%, diphtheria from 80.0% to 89.0%, hepatitis A from 50.1% to 60.8%, hepatitis B from 66.3% to 77.1%, and pneumococci from 62.8% to 76.3%. The influenza vaccination rate improved, but remained at a low level before (2010:13%, 2011:11.5%, 2012:19%) and during the intervention (2014:27.4%, 2015:24.4%, 2016:23.2%). Despite these vaccinations, the prevalence rates of the quality indicators standard vaccinations completed (2013:17.2%; 2016:21.2%), indicated vaccinations completed (2013:2.7%, 2016:4.5%), and all vaccinations completed (2013:1%; 2016 1.5%) improved only slightly.

Conclusions

Our results demonstrated that intensified communication by written information to the primary care physician and phone calls to the patients improved the number of vaccinations. Nonetheless, a potential for further improvement persists, especially with regard to annual influenza vaccinations.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

OBJECTIVES

To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as specified by Cochrane.

MAIN RESULTS

We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

AUTHORS' CONCLUSIONS

We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.

Patient reminder and recall interventions to improve immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.

OBJECTIVES

To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.

SELECTION CRITERIA

We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model.

MAIN RESULTS

The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).

AUTHORS' CONCLUSIONS

Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Hepatitis B vaccination uptake and correlates of serologic response among HIV-infected and uninfected men who have sex with men (MSM) in Bangkok, Thailand

BACKGROUND

Vaccination against hepatitis B virus (HBV) is recommended for all HBV-susceptible men who have sex with men (MSM). There is limited information on correlates of immunity to HBV vaccination in this group. We present serologic response rates to hepatitis B vaccine and identify factors associated with impaired response among HIV-uninfected and HIV-infected Thai MSM.

METHODOLOGY

HBV-susceptible volunteers were offered hepatitis B vaccination at months zero, one, and six. We measured baseline (pre-vaccination) total serum IgG and IgG subclasses (all participants), baseline CD4 count, and plasma HIV-1 viral load (PVL) (HIV+ participants). HBV serologies were retested at 12 months. Serologic responses were compared between all groups in men receiving three vaccine doses.

RESULTS

511/651 HIV-negative and 64/84 HIV-positive participants completed the three-dose series. Response rates in HIV-uninfected and -infected participants were 90.1% vs. 50.0% (p<0.0001). Median pre-vaccination IgG was higher among non-responders than responders overall (1238.9.0 vs. 1057.0mg/dL, p=0.003) and among HIV-infected participants (1534.0 vs. 1244.5mg/dL, p=0.005), but not significantly among HIV-uninfected participants (1105.5 vs. 1054.3mg/dL, p=0.96). Pre-vaccination IgG1 and IgG3 levels were higher among HIV-positive than HIV-negative participants (median 866.0 vs. 520.3, and 105.8 vs. 83.1mg/dL, respectively, p<0.0001). Among HIV-infected participants, median CD4 count in non-responders was 378 cells/μL vs. 431 cells/μL in responders (p=0.20). Median PVL in non-responders was 64,800 copies/mL vs. 15500 copies/mL in responders (p=0.04). Participants with pre-vaccination plasma IgG >1550 mg/dL and PVL >10,000 copies/mL were almost always non-responsive (p<0.01).

CONCLUSIONS

HIV infection was associated with poor vaccine responses. High plasma viral load, elevated pre-vaccination total serum IgG and elevated pre-vaccination IgG1 are associated with poorer response to vaccination among HIV-infected MSM. In this group, the combination of high PVL and pre-vaccination total IgG is highly predictive of vaccine failure.

Text message reminders do not improve hepatitis B vaccination rates in an Australian sexual health setting

OBJECTIVE

To evaluate the impact of text message reminders (short messaging service (SMS)) on hepatitis B virus (HBV) vaccination completion among high risk sexual health center attendees.

MATERIALS AND METHODS

In September 2008, Sydney Sexual Health Centre implemented an SMS reminder system. The authors assessed the impact of the reminder system on HBV vaccination rates among patients who initiated a course. The authors used a chi-square test and multivariate logistic regression to determine if SMS reminders were associated with second and third dose vaccine completion, compared with patients prior to the intervention.

RESULTS

Of patients sent SMS reminders in 2009 (SMS group), 54% (130/241) received 2 doses and 24% (58/241) received 3 doses, compared to 56% (258/463) (P = 0.65) and 30% (141/463) (P = 0.07) in the pre-SMS group (2007), respectively. Findings did not change after adjusting for baseline characteristics significantly different between study groups. There were no significant differences in completion rates among people who injected drugs, HIV-negative gay and bisexual men (GBM), and HIV-positive GBM. Among sex workers, travelers, and people who reported sex overseas, second and third dose completion rates were significantly lower in the SMS group compared to the pre-SMS group. In the SMS group, 18% of those who only had one dose attended the clinic within 1-18 months and 30% of those who had 2 doses attended in 6-18 months, but vaccination was missed.

DISCUSSION

SMS reminders did not increase second or third vaccine dose completion in this population.

CONCLUSION

Clinician prompts to reduce missed opportunities and multiple recall interventions may be needed to increase HBV vaccination completion in this high risk population.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain.

OBJECTIVES

To assess access, provider, system and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted influenza vaccine uptake data.

MAIN RESULTS

This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%). Increasing community demand (32 trials, 10 strategies)The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective. Enhancing vaccination access (10 trials, six strategies)The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250). Provider- or system-based interventions (17 trials, 11 strategies)The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective. Interventions at the societal level We identified no RCTs of interventions at the societal level.

AUTHORS' CONCLUSIONS

There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.

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.

Sexual transmission of viral hepatitis

Identification and vaccination of adults at risk for hepatitis B virus acquisition through sexual contact is a key strategy to reduce new hepatitis B virus infections among at-risk adults. Hepatitis C has emerged as a sexually transmitted infection among men with male sex partners (MSM). Several biological and behavioral factors have been linked to hepatitis C virus transmission among MSM, including human immunodeficiency virus coinfection; participation in sexual practices that result in mucosal damage or result in exposure to blood; presence of sexually transmitted diseases (STIs), particularly ulcerative STIs; multiple/casual sex partners; and unprotected anal intercourse.

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.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

Although the evidence to support influenza vaccination is poor, it is promoted by many health authorities. There is uncertainty about the effectiveness of interventions to increase influenza vaccination rates in those 60 years or older.

OBJECTIVES

To assess effects of interventions to increase influenza vaccination rates in those 60 or older.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1950 to July 2010), PubMed (January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and CINAHL (1982 to July 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) to increase influenza vaccination rates in those aged 60 years and older, recording influenza vaccination status either through clinic records, billing data or local/national vaccination registers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Forty-four RCTs were included. All included RCTs studied seniors in the community and in high-income countries. No RCTs of society-level interventions were included. Heterogeneity was marked and meta-analysis was limited. Only five RCTs were graded at low and six at moderate risk of bias. They included three of 13 personalized postcard interventions (all three with the 95% confidence interval (CI) above unity), two of the four home visit interventions (both with 95% CI above unity, but one a small study), three of the four reminder to physicians interventions (none with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity, and one P < 0.01). The other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn.

AUTHORS' CONCLUSIONS

Personalized postcards or phone calls are effective, and home visits, and facilitators, may be effective. Reminders to physicians are not. There is insufficient good evidence for other 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.

Compliance with multiple-dose vaccine schedules among older children, adolescents, and adults: results from a vaccine safety datalink study

OBJECTIVES

We studied compliance with multiple-dose vaccine schedules, assessed factors associated with noncompliance, and examined timeliness of series completion among older children, adolescents, and adults.

METHODS

We conducted a large, multisite, retrospective cohort study of older children, adolescents, and adults in the Vaccine Safety Datalink population from 1996 through 2004. We quantified the rates of completion of all required doses for varicella, hepatitis A, and hepatitis B vaccines according to their recommended schedules.

RESULTS

Among those who received a first dose of varicella (n = 16 075), hepatitis A (n = 594 917), and hepatitis B (n = 590 445) vaccine, relatively few completed the series (55%-65% for hepatitis B vaccine and 40%-50% for hepatitis A and varicella vaccines in most age groups). Compliance was lowest among adolescents (35.9%) and Medicaid recipients (29.7%) who received varicella vaccine and among younger adult age groups who received hepatitis A vaccine (25%-35% across those age groups). Even among series completers, there was a relatively long interval of undervaccination between the first and last doses.

CONCLUSIONS

Compliance with multiple-dose vaccine series among older children, adolescents, and adults is suboptimal. Further evaluations of strategies to improve compliance in these populations are needed.

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.

Predictors of first and second dose acceptance of hepatitis B vaccine among STD clinic patients

Our goal was to identify attitudinal, behavioural and pragmatic factors predictive of receipt of the first and second doses of hepatitis B virus (HBV) vaccine. In this study, 431 adult sexually transmitted disease clinic patients with no reported history of prior HBV vaccination or infection completed a computer-assisted questionnaire, then were offered free HBV vaccine. Those who accepted were scheduled for follow-up doses. Twenty-nine percent received the first dose of vaccine. Of these individuals, 21% returned for the second dose. Seven participants received all three doses. Health beliefs and caring for three or more children predicted first dose acceptance. Less travel time to the clinic and caring for two or fewer children predicted return for the second dose. HBV vaccination rates were low in this study. Interventions designed to modify health beliefs may increase first dose uptake. Increases in receipt of subsequent vaccine doses might best be accomplished through approaches designed to decrease pragmatic barriers to vaccine access.

Schedules for hepatitis B vaccination of risk groups: balancing immunogenicity and compliance

INTRODUCTION

Vaccination is an important tool in hepatitis B prevention. However, several vaccine doses are required to induce long-term protection. Several at-risk groups have difficulties in adhering to the standard vaccination schedule.

OBJECTIVES

This paper aims to review the use of accelerated hepatitis B vaccination schedules, in terms of immunogenicity and compliance.

RESULTS

Accelerated schedules (0.1.2.12 months) or super-accelerated schedules (0.7.21.360 days) have been shown to result in higher proportions of healthy vaccinees reaching anti-HBs antibody levels >or=10 IU/l more rapidly. A fourth completing dose is required to lift antibody levels to an equal height, as does a standard (0.1.6 months) schedule. Accelerated schedules do also increase the uptake of hepatitis B vaccine, that is the proportion of vaccinees who receive three doses. However, completing the schedule with a fourth dose is usually more difficult than completing a standard 0.1.6-month schedule. Several additional tools can help to increase the compliance (eg, reminder systems, outreach services and incentive schemes).

CONCLUSION

For rapid seroconversion and almost immediate protection in the short term, a (super)accelerated schedule could be used in at-risk groups. As long-term protection data with these (super) accelerated schedules have not been documented yet, a fourth dose at month 12 is still required. A shortened schedule (0.1.4 months) might be an alternative worth considering compared with the standard 0.1.6, as it convenes to internationally accepted minimum dose intervals and offers earlier protection. There is a clear need to study the long-term protection and effectiveness of the primary part of (super)accelerated schedules.

Hepatitis B vaccination in six STD clinics in the United States committed to integrating viral hepatitis prevention services

OBJECTIVES

Hepatitis B vaccination is recommended for clients of sexually transmitted disease (STD) clinics. The Healthy People 2010 goal is for 90% of STD clinics to offer hepatitis B vaccine to all unprotected clients. This report describes hepatitis B vaccination trends in six STD clinics in the United States and discusses implications for policy and practice.

METHODS

We conducted a retrospective study in six STD clinics to evaluate hepatitis B vaccination. We collected data on client visits and hepatitis B vaccinations for the period 1997-2005. To compare clinics, we calculated vaccination rates per 100 client visits. We interviewed staff to explore factors associated with hepatitis B vaccination trends.

RESULTS

STD clinic client visits ranged from 2,883 to 23,109 per year. The median rate of hepatitis B vaccination was 28 per 100 client visits. Vaccination rates declined in all six clinics in later years, which was associated with eligibility restrictions caused by fiscal problems and increasing levels of prior vaccination. The median rate of vaccine series completion was 30%. Staff cited multiple provider- and client-level barriers to series completion.

CONCLUSIONS

This study shows that STD clinics can implement hepatitis B vaccination and reach large numbers of high-risk adults. Adequate funding and vaccine supply are needed to implement current federal recommendations to offer hepatitis B vaccine to adults seen in STD clinics and to achieve the Healthy People 2010 objective.

Prevención de las hepatitis virales

Prevention of viral hepatitis infection involves health measures designed to avert transmission of viral agents and promote the use of gammaglobulin and vaccines. The availability of safe drinking water and improvements in quality of life result in better individual hygiene; these factors have had the greatest impact on hepatitis A prevention. Serum gammaglobulin administration has been replaced by vaccinations for pre-exposure, and to a great extent for post-exposure prophylaxis because of the progressively lower anti-HAV content of gammaglobulin and the short duration of the protective effect. Universal vaccination in childhood is the recommended measure for controlling hepatitis A. Adults belonging to high-risk groups should also undergo vaccination. The incidence of hepatitis B has decreased worldwide because of universal vaccination programs, initiated in preadolescence and childhood. Prevention of hepatitis C requires control of situations in which there is a likelihood of parenteral infection with the virus. Post-transfusion hepatitis has been virtually eradicated, but considerable effort is still needed to prevent nosocomial hepatitis.

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Changing epidemiology of hepatitis A in the Bologna metropolitan area, northern Italy: importance of counselling and prophylactic measures for the male homo/bisexual population

During a 6-year observational study, 122 cases of hepatitis A virus (HAV) infection were detected in Bologna, Italy, with a c. 300% increase in cases between 1999 and 2004. There were 104 cases (85.2%) in male adults, of whom nearly 70% had unprotected sexual contact as the probable risk-factor. There were increasing numbers of cases in immigrants between 1999 and 2004 (p 0.036), and concurrent cases of infection with human immunodeficiency virus, hepatitis B and C viruses and syphilis were also noted in adult males (p 0.0032). There is a need to re-emphasise targeted educational programmes and anti-HAV vaccination for at-risk subjects.

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.

Patient reminder and patient recall systems to improve immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result of low immunization rates, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care and large demands on primary care physicians, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. A common theme across immunization programs in all nations involves the challenge of determining the denominator of eligible recipients (e.g. all children who should receive the measles vaccine) and identifying the best strategy to ensure high vaccination rates. Strategies have focused on patient-oriented interventions (e.g., patient reminders), provider interventions and system interventions. One intervention strategy involves patient reminder and recall systems.

OBJECTIVES

To assess the effectiveness of patient reminder and recall systems in improving immunization rates and compare the effects of various types of reminders in different settings or patient populations.

SEARCH STRATEGY

A systematic search was performed for the initial review using MEDLINE (1966-1998) and four other bibliographic databases: EMBASE, PsychINFO, Sociological Abstracts, and CAB Abstracts. Authors also performed a search of The Effective Practice and Organisation of Care (EPOC) register in April 2001 to update the review. Two authors reviewed the lists of titles and abstracts and used the inclusion criteria to mark potentially relevant articles for full review. The reference lists of all relevant articles and reviews were back searched for additional studies. Publications of abstracts, proceedings from scientific meetings and files of study collaborators were also searched for references. In December 2004 the EPOC register was searched to identify relevant articles to update the review.

STUDY DESIGN

Randomized controlled trials (RCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies written in English.

TYPES OF PARTICIPANTS

Health care personnel who deliver immunizations and children (birth to 18 years) or adults (18 years and up) who receive immunizations in any setting.

TYPES OF INTERVENTIONS

Any intervention that falls within the EPOC scope (See Group Details) and that includes patient reminder or recall systems, or both, in at least one arm of the study.

TYPES OF OUTCOME MEASURES

Immunization rates or the proportion of the target population up-to-date on recommended immunizations. Outcomes were acceptable for either individual vaccinations (e.g. influenza vaccination) or standard combinations of recommended vaccinations (e.g. all recommended vaccinations by a specific date or age).

DATA COLLECTION

Each study was read independently by two reviewers. Disagreements between reviewers were resolved by a formal reconciliation process to achieve consensus.

ANALYSIS

Results are presented for individual studies as relative rates for randomized controlled trials and as absolute changes in percentage points for controlled before and after studies. Pooled results for RCTs only were presented using the random effects model.

MAIN RESULTS

Five new studies were added for this update. Increases in immunization rates due to reminders were in the range of 1 to 20 percentage points. Reminders were effective for childhood vaccinations (OR = 1.45, 95% CI =1.28, 1.66), childhood influenza vaccinations (OR = 2.87, 95% CI = 1.65, 4.98), adult pneumococcus, tetanus, and Hepatitis B (OR = 2.19, 95% CI = 1.21, 3.99), and adult influenza vaccinations (OR = 1.66, 95% CI = 1.31, 2.09). All types of reminders were effective (postcards, letters, telephone or autodialer calls), with telephone being the most effective but most costly.

AUTHORS' CONCLUSIONS

Patient reminder and recall systems in primary care settings are effective in improving immunization rates within developed countries.