Routine hepatitis B vaccination in a clinic for sexually transmitted diseases

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.

Low rates of free human papillomavirus vaccine uptake among young women

OBJECTIVE

To determine uptake of quadrivalent human papillomavirus recombinant vaccine (quadrivalent; Gardasil((R)), Merck, New Jersey, USA) offered under optimal conditions to women 18 to 24 years of age, and to identify predictors of uptake.

METHODS

Young women (n = 209) were recruited from a university health clinic. After completing a self-administered questionnaire, women received a free voucher for the entire vaccine series.

RESULTS

Only 59 women (28.2%) who were offered this free service completed the series. Just over half (50.7%) received the first dose. Of those, 78.3% returned to receive the second and 55.7% returned for the third. Young women who felt their mothers might not want them to be vaccinated were much less likely to complete the series compared with those who felt their mothers would 'definitely' want them to be vaccinated (P = 0.0002). Also, young women who indicated that they would take the time to return to the clinic for doses two and three were far more likely to complete the series (P = 0.0004). Several measures failed to achieve even bivariate significance with vaccine uptake, including being sexually active in the past 12 months, ever having a Pap test or an abnormal Pap test result, and ever having a sexually transmissible infection.

CONCLUSIONS

Even under ideal conditions, uptake of Gardasil among women 18-24 years of age may be quite low. Maternal endorsement and young women's perceptions about the time needed to return for subsequent doses are important determinants of vaccine uptake. Fortunately, these two determinants lend themselves to intervention efforts.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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 Infection and Vaccination Among High-Risk Noninjection Drug-Using Women: Baseline Data From the UNITY Study

OBJECTIVES

Few studies of hepatitis B virus (HBV) infection and hepatitis B vaccination have focused on women, and specifically, women who are at high risk. This study was designed to assess the extent of HBV infection and vaccination, level of knowledge about hepatitis B, motivators and barriers to accepting vaccination and uptake of hepatitis B vaccine.

DESIGN

From March 2005 to June 2006, 402 HIV-negative noninjection drug-using women at sexual risk were recruited, interviewed, and tested for markers of HBV infection.

RESULTS

Based on serologic testing, 16.7% were previously vaccinated against HBV, 31.1% were previously infected and 52.2% were still susceptible to HBV. Knowledge of HBV infection, transmission, and prevention was low with a mean of 6.1 of 12 knowledge items correctly identified as true or false; a substantial percent of women were not sure of the correct answer. Of the women still susceptible, 69.0% started the hepatitis B vaccine series after counseling given through the study.

CONCLUSION

This study illustrates that there continues to be gaps in current strategies for administering hepatitis B vaccine among female populations at sexual risk. Interventions are needed for this population to increase awareness and knowledge of hepatitis B, its transmission, impact on health and the availability of a safe and effective vaccine, supplemented by community programs for adult vaccination.

Hepatitis B vaccination of men who have sex with men attending an urban STD clinic: impact of an ongoing vaccination program, 1998-2003

OBJECTIVE

To evaluate the impact of an ongoing hepatitis B vaccination service offered in an urban sexually transmitted disease (STD) clinic.

STUDY DESIGN

During the period 1998-2003, hepatitis B vaccine acceptance, series completion, and vaccine coverage rates were evaluated among men who have sex with men (MSM) and other clients attending the main STD clinic in San Diego County, California.

RESULTS

Among 21,631 STD clinic attendees, 81% were eligible to start and 69% accepted hepatitis B vaccination. Among a cohort of MSM starting vaccination in 1998, 76% and 55% received 2 doses and 3 doses, respectively, after 1 year follow-up and coverage then increased 1-2 percentage points annually to a final 2-dose and 3-dose coverage of 80% and 62%, respectively. Vaccine coverage (>=1 prior vaccine dose) among STD clinic attendees in 2003 was 45% compared to only 11% in 1998, the first year of the program.

CONCLUSIONS

Hepatitis B vaccination can be integrated into STD clinic services with reasonable levels of vaccine acceptance and series completion. The increase in vaccination coverage over time indicates that a sustained hepatitis B immunization program can achieve acceptable vaccine coverage in high-risk populations.

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

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

Integrating hepatitis, STD, and HIV services into a drug rehabilitation program

BACKGROUND

Considering the difficulties in providing screening and vaccination services for inmates in short-stay incarceration facilities, an evaluation was conducted of the integration of prevention services in an alternative sentencing drug rehabilitation program (alternative to incarceration) in San Diego CA.

METHODS

During the period April 1999 to December 2002, clients were asked to complete a brief risk-assessment questionnaire, and were offered hepatitis B virus (HBV) vaccination, HBV and hepatitis C virus (HCV) serologic testing, STD screening, and HIV counseling and testing.

RESULTS

Of the estimated 1125 rehabilitation program enrollees, 930 (83%) participated in the integration program services. Most clients were male (64%), were aged >30 years (64%), and few (7%) reported previous HBV vaccination. Of the 854 clients eligible for hepatitis B vaccination, 98% received the first dose, 69% the second dose, and 42% completed the series. Eleven percent of clients had prior HBV infection, and 14.7% had HCV infection, with positivity rates being highest among those with a history of injection drug use-HBV, 19%, and HCV, 36%. HIV infection was rare (prevalence, 0.3%), and STDs were uncommon (chlamydia prevalence, 2%, and gonorrhea prevalence, 0.6%). Total annual cost of integration services (excluding HIV testing) was dollar 31,994 equating to dollar 122 per client served.

CONCLUSIONS

Alternative sentencing drug rehabilitation programs provide a venue to efficiently deliver integrated hepatitis and other prevention services. Considering the vast number of high-risk persons in drug rehabilitation, probation, parole, and inmate release programs, an opportunity exists to greatly expand hepatitis services.

Review of Clinical Trials Testing the Effectiveness of Clinician Intervention Approaches to Prevent Sexually Transmitted Diseases in Adolescent Outpatients

OBJECTIVE

Identify approaches for improving clinician provision of sexually transmitted diseases (STDs) prevention services among outpatient adolescents.

METHODS

Reviewed all peer-reviewed, published clinical trials identified through computerized searches (MEDLINE, PsychINFO) evaluating STD prevention services to outpatient adolescents by clinicians.

RESULTS

Five trials were identified examining changes in clinician provision of STD prevention services. Two of these trials resulted in adolescent self-reported risk reduction but neither of these trials effectively demonstrated reductions in objectively measured STD incidence. Nine clinical trials were identified that compared clinician with non-clinician provision of STD prevention services. Four of these trials resulted in adolescent self-reported risk reduction, and one of these trials demonstrated a reduction in objectively measured STD incidence.

CONCLUSIONS

Trials indicate that improvement in outpatient adolescent STD incidence is possible with non-clinicians as interventionists, and perhaps clinicians as interventionists if clinicians are supported by other educational resources. Opportunities for personalized, interactive adolescent education appears key to intervention success. The clinician role that is tested in most trials is confined to a single brief encounter with little attention to: development of clinician skills, quality of psychosexual risk assessment and tailoring to meet individual adolescent need, systems-level resources and supports, the parental role, or the impact of incorporating prevention into an ongoing adolescent-clinician relationship.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND AND OBJECTIVES

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

GOAL

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

GOAL

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

GOAL

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Association of hepatitis C virus infection with sexual exposure in southern India

To determine the association between sexual exposure and hepatitis C virus (HCV) infection in urban Chennai, India, a random sample of adults who live in a slum community completed interviews and provided samples to test for HCV, herpes simplex virus type 2 (HSV-2), and other sexually transmitted infections (STIs). All analyses excluded recent and current injection drug users. HCV infection was not associated with the reported number of sex partners for men or women. Women were more likely to be HCV infected if they reported previous genital ulcer disease (adjusted odds ratio [AOR], 3.88; 95% confidence interval [95% CI], 0.94-16.0; marginally statistically significant). Men were more likely to be HCV infected if they were HSV-2 infected (AOR, 3.85; 95% CI, 1.18-12.6) or reported having had sex with men (AOR, 3.61; 95% CI, 1.00-13.1). Sexual transmission of HCV infection may be facilitated by ulcerative STIs and male-male sexual practices, but it appears to occur infrequently in this population.

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

BACKGROUND

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

GOAL

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

A review of the case for hepatitis B vaccination of high-risk adults

The sequelae of hepatitis B virus infection include fulminant liver failure, chronic liver disease, hepatocellular carcinoma, and death. The hepatitis B vaccine is efficacious, safe, and cost-effective, but has been consistently underutilized in high-risk adults despite long-standing recommendations. Instituting routine hepatitis B vaccination for high-risk adults in settings such as prisons and jails, sexually transmitted disease clinics, drug treatment centers, and needle exchange programs could prevent up to 800 cases of hepatitis, and 10 deaths from hepatitis, per 10,000 vaccinations, with an overall cost savings. Low rates of completion of the three-dose series and lack of funding for adult immunizations have always been challenges to offering hepatitis B vaccines to high-risk adults. However, there is benefit to an incomplete vaccination series, and high-risk populations are accessible for follow-up vaccination outside of traditional medical settings. A clear national objective and federal funding for vaccinating high-risk adults are needed.

Acceptance of hepatitis B vaccination among adult patients with sexually transmitted diseases

BACKGROUND

Sexually transmitted disease (STD) clinic patients are at risk for hepatitis B virus infection, but have been relatively neglected in terms of hepatitis B virus (HBV) immunization. Acceptance of HBV vaccine among patients attending an STD clinic was examined.

GOAL

To evaluate potential predictors of HBV vaccine acceptance.

STUDY DESIGN

In this study, 99 patients attending an STD clinic completed a brief questionnaire that addressed knowledge of STD and vaccines as well as sexual behavior. After the questionnaire, each patient was offered HBV vaccine, then interviewed to assess reasons for acceptance or refusal.

RESULTS

Among the patients in this study, 23% accepted the vaccine and 11% reported prior vaccination. Acceptors were younger, had less education, and used condoms less frequently than those who refused vaccination. The reasons given for acceptance or rejection typically involved health beliefs related to infection or vaccination.

CONCLUSION

The findings indicate an unacceptably low rate of HBV vaccine acceptance in a group at high risk for infection. However, some of the reasons for refusal may be modifiable through brief, targeted interventions.

Two decades after vaccine license: hepatitis B immunization and infection among young men who have sex with men

OBJECTIVES

This study investigated hepatitis B immunization coverage and the extent of hepatitis B virus (HBV) infection among young men who have sex with men (MSM), a group for whom hepatitis B vaccine has been recommended since 1982.

METHODS

We analyzed data from 3432 MSM, aged 15 to 22 years, randomly sampled at 194 gay-identified venues in 7 US metropolitan areas from 1994 through 1998. Participants were interviewed, counseled, and tested for serologic markers of HBV infection.

RESULTS

Immunization coverage was 9% and the prevalence of markers of HBV infection was 11%. HBV infection ranged from 2% among 15-year-olds to 17% among 22-year-olds. Among participants susceptible to HBV infection, 96% used a regular source of health care or accessed the health care system for HIV or sexually transmitted disease testing.

CONCLUSIONS

Despite the availability of an effective vaccine for nearly 2 decades, our findings suggest that few adolescent and young adult MSM in the United States are vaccinated against hepatitis B. Health care providers should intensify their efforts to identify and vaccinate young MSM who are susceptible to HBV.

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

BACKGROUND

Hepatitis B virus infection causes substantial morbidity and mortality in the United States. Sexual activity is the most commonly reported risk factor among persons with acute hepatitis B, yet hepatitis B vaccine coverage among adolescents and adults with high-risk sexual practices is low. Sexually transmitted disease (STD) clinics are potentially efficient settings for vaccine administration to persons with high-risk sexual practices; however, little is known about hepatitis B vaccination activities in these settings.

GOAL

To gain information about policies and activities for vaccinating against hepatitis B in STD clinic settings.

STUDY DESIGN

In April 1997, a questionnaire was sent to managers of 65 federally funded STD programs in state and local health departments. A similar survey was sent to 89 STD clinic managers in November 1997.

RESULTS

The response rate among program managers was 97% (63/65). Forty-eight percent considered hepatitis B prevention a program responsibility; 21% had developed and distributed written policies to prevent hepatitis B through vaccination; and 27% had developed policies to encourage hepatitis B education activities. The response rate among clinic managers was 82% (73/89). Forty-five percent reported that their STD clinics had implemented policies recommending hepatitis B vaccination and health education activities. Program managers and clinic managers reported that lack of funding to cover the cost of the vaccine, and lack of resources to provide prevaccination counseling, administer vaccine, and track clients for vaccine series completion were the primary barriers to the implementation of hepatitis B vaccination programs.

CONCLUSIONS

To enhance hepatitis B vaccination in STD clinics, existing funding sources must be accessed more effectively. Supplemental funding mechanisms for the cost of vaccine and resources for implementing vaccination programs also need to be identified. Additionally, STD clinics and programs should continue to propose and implement hepatitis B vaccination policies.

Risk of hepatitis B infection among young injection drug users in San Francisco: opportunities for intervention

OBJECTIVE

To compare the demographic characteristics and risk behaviors for hepatitis B infection among injection drug users younger than 30 years with those aged 30 or older and to evaluate participants' knowledge, attitudes, and experiences of infection, screening, and vaccination against hepatitis B virus.

DESIGN

A systematic sample of injection drug users not currently in a treatment program were recruited and interviewed at needle exchange programs and community sites.

PARTICIPANTS

135 injection drug users younger than 30 years and 96 injection drug users aged 30 or older.

RESULTS

Injection drug users younger than 30 were twice as likely as drug users aged 30 or older to report having shared needles in the past 30 days (36/135 [27%] vs 12/96 [13%]). Injection drug users younger than 30 were also twice as likely to report having had more than two sexual partners in the past 6 months (80/135 [59%] vs 29/96 [30%]). Although 88 of 135 (68%) young injection drug users reported having had contact with medical providers within the past 6 months only 13 of 135 (10%) had completed the hepatitis B vaccine series and only 16 of (13%) perceived themselves as being at high risk of becoming infected with the virus.

CONCLUSION

Few young injection drug users have been immunized even though they have more frequent contact with medical providers and are at a higher risk for new hepatitis B infection than older drug users. Clinicians caring for young injection drug users and others at high risk of infection should provide education, screening, and vaccination to reduce an important source of hepatitis B infection.

Evaluation of office-based intervention to improve prevention counseling for patients at risk for sexually acquired hepatitis B virus infection. Hepatitis B-WARE Study Group

The aim of this study was to determine the effectiveness of tools to identify and counsel patients at risk for sexually transmitted hepatitis B virus infection. Physicians were randomly assigned to either an intervention group or a control group. The intervention group was provided with materials intended to encourage patients to return for counseling and to guide counseling concerning prevention of hepatitis B virus infection. Baseline data on 457 patients at risk for hepatitis B virus infection showed that 7% had received prevention counseling and 2% had begun hepatitis B vaccination. Counseling was least likely to occur in obstetric-gynecologic practices, among uninsured patients, and among patients whose only risk factor was a diagnosis of a sexually transmitted disease. After a 6-month intervention period 26% of the intervention group patients and 7% of the control group patients had been counseled (P <.01). Vaccination was more likely among intervention group patients (8% vs <1%; P <.001). The use of tools to identify and counsel patients at risk for sexually transmitted hepatitis B virus infection resulted in increased office-based prevention activities.

Hepatitis B vaccine administered to children and adolescents at yearly intervals

OBJECTIVE

Hepatitis B vaccines are usually administered on a schedule of 0, 1 to 2, and 6 months. Longer intervals between the second and third doses have been studied, but the effectiveness of hepatitis B vaccine administered at intervals of >2 months between the first and second doses have not been studied. Our objective was to compare the antibody response in recipients of Engerix-B hepatitis B vaccine administered at 12-month intervals to the response to vaccine administered at 0-, 1-, and 6-month intervals.

METHODS

A total of 389 children, 5 through 16 years of age, were randomized to receive Engerix-B (10 mg) at a schedule of either 0-, 1-, and 6-month intervals or 0-, 12-, and 24-month intervals. Blood was drawn before and 1 month after the third dose.

RESULTS

Immediately before the third dose of vaccine, 92.3% of children who received vaccine on the 0-, 1-, and 6-month schedule and 88.8% of children who received the 0-, 12-, and 24-month schedule had antibody to hepatitis B surface (anti-HBs) antigen concentrations >/=10 mIU/mL. Of the children in the 0-, 1-, and 6-month schedule, 95% received the third dose according to protocol versus 90% of those in the 0-, 12-, 24-month schedule. The geometric mean anti-HBs concentration just before the third dose for recipients of the 0-, 1-, and 6-month schedule (117.9 mIU/mL) was somewhat lower than that for the children who had received vaccine on the 0-, 12-, and 24-month schedule (162.1 mIU/mL). One month after the third dose, >98% of all children had anti-HBs concentrations >/=10 mIU/mL and high geometric mean antibody concentrations were observed in both groups: 5687 mIU/mL for children on the 0-, 1-, and 6-month schedule and 3159 mIU/mL for children on the 0-, 12-, and 24-month schedule. Body mass index was correlated inversely with final antibody concentration, but age was not a factor after adjustment for body mass index.

DISCUSSION

Engerix-B administered on a 0-, 12-, and 24-month schedule is highly immunogenic. Providers should consider this alternate immunization schedule for children who are at low risk of immediate exposure to hepatitis B infections.

Susceptibility to vaccine-preventable diseases in a sexually transmitted disease clinic population

BACKGROUND AND OBJECTIVE

Sexually transmitted disease (STD) clinics often serve a population that has low medical care utilization. The objective of this study was to determine the susceptibility of an STD clinic population to vaccine-preventable diseases.

STUDY DESIGN

A cross-sectional study of immunization practices and susceptibility to vaccine-preventable diseases was undertaken by enrolling consecutive patients attending an STD clinic. Demographic information and a history of disease or immunization was assessed by interview. Immunity to measles and rubella was determined by measuring IgG antibodies by ELISA assays.

RESULTS

Of the 288 patients evaluated, the mean age was 28 years and 70.5% were male. Serologically, 16.3% were susceptible to rubella and 8% to measles. Only 8% reported hepatitis B immunization. Although measles protection was high, nearly one in six was susceptible to rubella. Hepatitis B immunization was severely underused.

CONCLUSION

Baltimore STD clinic patients may benefit from an enhanced rubella and hepatitis B prevention strategy.

School-based adolescent hepatitis B immunization programs in the United States: strategies and successes

BACKGROUND

To increase hepatitis B vaccination coverage of adolescents, a public/private partnership was organized in the greater Baton Rouge area of Louisiana in 1992 to fund and implement school-based vaccination programs.

METHODS

Initial programs utilized schools with existing school-based clinics and administered 2 to 3 doses of hepatitis B vaccine to up to 76% of eligible students. During 1996 to 1997, expansion from 4 schools to 68 schools was facilitated by the use of temporary clinics set up in open school space. This multifaceted program administered 3 doses of hepatitis B vaccine to 3232 students (75%) and 2 doses to 171 students (4%). Administration of the 3-dose regimen of hepatitis B vaccine was aided by the use of a dosing schedule at 0, 2 and 4 months. This accelerated dosing has been shown to provide seroprotection for greater than 95% of healthy adolescents.

RESULTS

In the Baton Rouge area, the hepatitis B adolescent vaccination program has immunized approximately 5000 adolescents during a 5-year period with minimal use of financial and personnel resources.

CONCLUSIONS

The success and growth of this program demonstrate that school-based vaccination programs can be highly efficient and effective.

Epidemiologic support to state and local sexually transmitted disease control programs. Perceived need and availability. The Field Epidemiology Network for STDs (FENS)

BACKGROUND AND OBJECTIVES

Sexually transmitted diseases (STDs) comprise the majority of national infectious disease morbidity reported, yet the number of epidemiologists working in state and local STD programs is estimated to be small. Even less is known about the training and activities of those epidemiologists.

GOALS

To determine the number, training, and affiliation of epidemiologists working with STD programs and the level of satisfaction with epidemiologic support available.

STUDY DESIGN

Survey of 65 program managers in state and local health departments.

RESULTS

Program managers named 146 people working on epidemiologic activities, and 84 of those people were classified as "epidemiologist" by the criteria we applied. The median number of full-time equivalent (FTE) epidemiologists working in or with STD programs was 0.5; one quarter of all STD program had no epidemiologists. There was a significant association between number of FTE epidemiologist and population, with most programs with more than 0.5 epidemiologists located in areas with at least 1,000,000 population. State Epidemiologists do not provide technical support to most state STD programs. Almost half (45%) of all program managers indicated that they have inadequate epidemiologic support for routine program activities.

CONCLUSIONS

The current level of epidemiologic support available to most STD programs is inadequate to perform surveillance and data analyses, interpret data to develop program objectives, and perform program evaluation. An essential next step is the delineation of a set of critical, analytic STD field epidemiology functions to define appropriate standards against which epidemiologic capacity can be more precisely measured.

Prevalence and risk factors for hepatitis B virus infections among visitors to an STD clinic

OBJECTIVE

To determine the prevalence and risk factors for hepatitis B virus (HBV) infections among individuals attending an STD clinic in a low endemic region.

STUDY DESIGN

A total of 1228 women and 1648 men attending the STD clinic at the University Hospital Rotterdam, Netherlands, were examined for HBV infection by determination of hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B core antigen (anti-HBc). Demographic characteristics, information on sexual behaviour, and intravenous drug use were recorded.

RESULTS

The seroprevalence of HBsAg was 1.4% in women and 2.1% in men (0% in homosexual men). The seroprevalence of anti-HBc was 13% in women and 20% in men (36% in homosexual men). Native country, intravenous drug use, a history of STD, and the number of partners in the past half year (inversely) were independent risk factors for HBsAg positivity in women and heterosexual men. For anti-HBc independent associations were observed for native country, age, intravenous drug use, commercial sex, number of lifetime partners, homosexual contacts, orogenital contact (inverse), and a history of STD.

CONCLUSION

The HBV prevalence in the STD clinic attendants was high, exceeding the national estimate, and indicates that the STD clinic population may be considered a high risk group. Our data confirmed an increased risk for HBV infections among established risk groups. Therefore, these risk groups should be routinely screened to identify HBV cases for counselling and contact tracing.