Author: Nickell, S P; Winter, K; Talarico, J; Bolan, G; Miller, J; McLean, R; King, H; Weinbaum, C; Holtzman, D; Ward, J W; Mootrey, G; Weiss, E; Yu, Y
Date published: May 7, 2010
Journal code: IMMW
Since hepatitis B vaccine was first released in 1 98 1 , a public health goal has been to vaccinate adults at risk for infection because of risky sexual behaviors and needle-sharing practices (1,2). However, vaccination coverage for this group has remained low (3). During 2007, in the United States, among the estimated 43,000 persons newly infected with hepatitis B virus (HBV), the highest rate was reported among persons aged 25^44 years, and the majority of these infections were among at-risk adults (1). Surveillance data were similar in California (4). In 2006, when the Advisory Committee on Immunization Practices (ACIP) recommended that hepatitis B vaccination be offered to all adults as part of routine prevention services in settings where a high proportion of those served are at increased risk (2,3), CDC launched a national initiative encouraging states to use existing federal funds to purchase adult hepatitis B-containing (HepB) vaccine. In response, the California Department of Public Health (CDPH) established the Adult Hepatitis Vaccine Project (AHVP) to expand hepatitis B vaccination in sites serving at-risk adults. This report summarizes results for 2007-2008, which indicated that 28,824 doses of HepB vaccine were administered at 29 participating sites in the first 19 months of AHVP; 13 sites administered HepB vaccine for the first time. Federal provision of vaccine resulted in vaccination of many adults who otherwise might not have been vaccinated against HBV Increased capacity to vaccinate all adults at risk is needed for the elimination of HBV transmission in the United States.
In October 2006, CDC encouraged state and local immunization programs to use portions of federally appropriated vaccine funds to offer or expand adult hepatitis B vaccination in selected health-care sites that reach adults at increased risk for HBV infection. One year later, in October 2007, CDC made available $20 million of federal funds* for the purchase of adult HepB vaccine. As part of this national initiative, the California AHVP was established. Trie AHVP selected sites for participation based on 1) type of setting serving at-risk adults, in accordance with ACIP recommendations, 2) a feasible plan to integrate immunization services into other activities, 3) ability to properly handle and administer vaccine, including local licensed staff and storage capability, 4) ability and willingness to document vaccine administration, and 5) availability of local funds to pay for syringes, needles, and other vaccine supplies. Phase I (June-October 2007) of AHVP began when CDPH used funds from the CDC initiative for purchase of adult HepB vaccine; phase II (November 2007-December 2008) was implemented when additional federal funds were made available by CDC to California and other states to purchase HepB vaccine for settings serving at-risk adults.
AHVP asked participating sites to collect data on the number of vaccine doses administered during both phases of the project. In addition, AHVP requested demographic information (age, sex, race, and ethnicity) for each person who received vaccine, as well as which dose of the 3-dose series was administered. For this report, the monthly average number of adults who received vaccine was calculated by whether vaccine services were provided by the site (none versus some services) and by funding phase. Data were analyzed by demographic characteristics and by type of site for all adults who received a first dose. Because no data on the number of vaccine-eligible adults at each site were available routinely, coverage rates could not be calculated.
A total of 29 sites were enrolled in the California AHVP during June 2007-December 2008, including 11 sexually transmitted disease (STD) clinics, four correctional facilities, four community health centers, four substance abuse treatment programs, four syringe exchange programs, and two HIV counseling, testing, and treatment sites. Of the 28,824 doses of HepB vaccine administered during the 19-month period (60% of the 47,795 doses purchased by California), 15,865 were first (55%), 8,488 second (29%), and 4,165 (14%) third doses (the remainder were fourth doses or had missing series data). Twelve sites serving at-risk adults among the agencies and organizations were selected for participation in phase I; an additional 17 smaller sites were added in phase II. On average, 1,123 doses of HepB vaccine were administered each month at the initial 12 sites in phase I, increasing to 1,285 doses per month in phase II (a 14% increase). Among sites with no previous vaccination services, the monthly average number of HepB vaccine doses administered increased from 809 doses in phase I to 842 doses in phase II; among sites where some vaccination services were offered, the average number of doses increased from 314 to 443. The 17 new sites in phase II delivered a monthly average of 367 doses of vaccine. Thirteen of the 29 sites did not offer any adult hepatitis B vaccination services before AHVP.
Of 15,865 first doses administered by all participating sites, 72% were administered to males and 27% to females (Table). Seventy-four percent of first doses were administered to adults aged 19-44 years. By site, 63% of first doses were administered in STD clinics, 22% in correctional facilities, 7% in community health centers, 4% in substance abuse treatment programs, 3% in syringe exchange programs, and 1% in HIV counseling, testing, or treatment sites.
As a result of the California AHVP, HepB vaccine was offered at no cost to local public health programs and community organizations serving at-risk adults, thereby removing a major barrier to HBV vaccination. Sites that previously had not offered free HepB vaccine delivered more than two thirds of the total doses supplied by AHVP. Although no data were available to measure coverage or HepB vaccination series completion rates, these results still demonstrate that sites were able to offer and deliver HepB vaccine to adults in large numbers, without additional federal resources for staff time. The increases in the monthly average number of doses in the latter part of the program, although modest, suggested that an unmet need for HepB vaccine existed at the end of 2008.
Some sites adopted innovative strategies to improve their services. Two correctional facilities recorded vaccine administration in their local immunization registry to facilitate data access by other medical providers in the community. Other sites optimized patient compliance with vaccination series completion by sending reminder cards or offering expedited service to clients who returned for follow-up doses.
At the national level, during June 2007-December 2008, the CDC initiative, in collaboration with 51 state and local vaccination programs and viral hepatitis prevention coordinators, supported the administration of 275,445 doses of HepB vaccine in 1,065 sites. Of the total number of vaccine doses delivered nationally, most were administered by local health departments (37%) and STD clinics (30%), followed by correctional facilities (22%). California administered 10.5% of the national doses available through the CDC initiative, a majority of which were administered in local STD clinics. California administered the second largest number of HepB vaccine doses in STD clinics of any state (CDC, unpublished data, 2010). In 2008 and 2009, CDC distributed an additional $16 million each year to state and local grantees to sustain support for purchase of adult HepB vaccine. Future support of the CDC initiative depends on available funding.
The findings in this report are subject to at least three limitations. First, because the federal funds could not be used for administrative support, tracking of vaccine doses administered depended on local resources. Consequently, a few AHVP sites (<6%) did not routinely report vaccine administration data; thus, administered doses likely were underreported. Second, because sites did not report coverage rates or series completion rates routinely, these data were not available. Finally, for all sites except the 13 that administered HepB vaccine for the first time, the number of HepB vaccine doses being administered by the sites before implementation of AHVP was not available; thus, doses administered before and after the project could not be compared.
The AHVP experience demonstrates that HepB vaccine, when supplied at no or small cost, can be delivered as part of existing clinical services to a substantial number of previously unvaccinated, at-risk adults in various settings. However, AHVP and similar programs in other states have not had the capacity to vaccinate all adults at risk for HBV infection as recommended by ACIP (2). In a recent report, the Institute of Medicine estimated that approximately $80 million is needed to vaccinate 75% of adults in STD/HIV and drug treatment centers alone (6). Increases in funding for immunization and changes in health insurance coverage represent important opportunities to increase vaccination coverage among adults and help achieve the goal of eliminating HBV transmission in the United States (7).
* 42 USC § 274b (project grants for preventive services).
1. CDC. Surveillance for acute viral hepatitis - United States, 2007. MMWR2009;58(No. SS-3).
2. CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR2006;55(No. RR- 16).
3. CDC. Hepatitis B vaccination coverage among adults - United States, 2004. MMWR 2006;55:509-11.
4. California Department of Public Health. Vaccine-preventable diseases in California, 2002-07. Richmond, CA: California Department of Public Health; 2009. Available at http://www.cdph.ca.gov/programs/immunize/documents/vaccinepreventablediseasesca2002-07.pdf. Accessed April 29, 2010.
5. CDC. Hepatitis B vaccination among high-risk adolescents and adults- San Diego, California, 1998-2001. MMWR 2002;51:618-21.
6. Institute of Medicine. Hepatitis and liver cancer: a national strategy for prevention and control of hepatitis B and C. Washington, DC: National Academies Press; 2010. Available at http://www.iom.edu/reports/2010/hepatitis-and-liver-cancera-national-strategy-for-prevention-and-control-of-hepatitis-band-c.aspx. Accessed April 29, 2010.
7. CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40 (No. RR-13).
SP Nicheli, PhD, KWinter, MPH.JTakrico, DO, GBoUn, MD, J Miller, MPH, R McLean, MPH, Center of Infectious Diseases, California Dept of Public Health. H King, MPH, C Weinbaum, MD, D Holtzman, PhD, JW Ward, MD, Div of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; G Mootrey, DO, Immunization Svc Div, National Center for Immunization and Respiratory Diseases; E Weiss, MD, Office of Workforce and Career Development; Y Yu, PhD, EIS Officer, CDC.