Hepatitis B Vaccination Coverage among High-risk Adults Aged 18 - 49 Years, United States, 2008 Pengjun Lu, PhD, MPH;1 Kathy Byrd, MD, MPH;2 Trudy Murphy, MD;2 Cindy Weinbaum, MD, MPH;2 1Immunization Services Division, National Center for Immunization and Respiratory Diseases, 2 Division Of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD,& TB Prevention Centers for Disease Control and Prevention

Hepatitis B (HBV) Disease Burden, United States Hepatitis B causes significant morbidity 1 in 20 persons ever infected with hepatitis B virus (12.5 million) 43,000 persons newly infected in 2007 95% of new cases were in adults 800,000 – 1.4 million persons with chronic HBV infection 2,000 – 4,000 deaths / year

Incidence of Acute Hepatitis B, 1980 - 2006 Vaccine for certain groups (1982) All Infant immunization (1991) All birth dose (2005) All Adolescent immunization (1995) Recombinant vaccine licensed (1986) Adults at risk (2006) This slide shows the rate of new cases of acute hepatitis B from 1980 – 2006. Cases of acute hepatitis B peaked around 1985 and have since steadily declined. From 1985 to 2006 the incidence has decreased 86%. Several strategies to decrease hepatitis B transmission where implemented over this time period. In 1982 vaccination for hepatitis B was recommended for certain groups. The recombinant hepatitis B vaccine was licensed in 1986. Universal infant vaccination was recommended in 1991 with routine vaccination of previously unvaccinated children and adolescents in 1995. And universal vaccination of newborns was recommended in 2005.

Revised Hepatitis B Vaccine Recommendations for Adults (2006) High risk adults, including Household contacts and sex partners of HBV carriers Injecting drug users Men who have sex with men Multiple sex partners HIV positive Hemodialysis patients Hemophilia with clotting factors Universal vaccination in settings serving high-risk adults Partially based on the data that I just showed you, in 2006, the Advisory Committee on Immunization Practices revised their recommendations for hepatitis B vaccination in adults To include universal hepatitis B vaccination for settings serving adults at high risk for hepatitis B infection including: STD clinics HIV testing and treatment facilities Correctional facilities including both prisons and jails Substance abuse treatment facilities and Others such as institutions for the developmentally disabled

Study Objective Estimate HBV vaccination coverage in high-risk adults aged 18 – 49 years 2008 National Health Interview Survey

National Health Interview Survey (NHIS) In-home household interview survey Conducted by U.S. Census Bureau for the National Center for Health Statistics Civilian non-institutionalized population residing in the United States Random sample of ~48,000 households annually Over 20,000 respondents in 2008

Methods Weighted proportion of self-reported HBV vaccination coverage (≥1 dose) determined by risk group and characteristic Age group Sex Race / ethnicity Education level Above high school or high school and below Insurance status Ever tested for HIV

Case Definition: Risk Group High risk: any of the following apply Male sex with men Injection drug use Hemophilia with clotting factors Sex for money or drugs HIV positive Sex with any of the above Multiple sexual partners STD in past 5 years (other than HIV) or responded that HIV risk was high Low risk: none of the above

Analysis Comparison of vaccination coverage (high versus low risk) by age groups using Pearson’s Χ2 test Independent predictors of vaccination determined by multivariate logistic regression Vaccination coverage compared with the 2004 NHIS estimation of coverage in high-risk adults

Demographics and Characteristics of Persons aged 18 – 49 years “High risk” “Low risk” Median age (years) 34 35 n % Total (unweighted) 852 6.6 10,859 93.4 Male 366 47.6 4,897 49.6 White, non-Hispanic 455 63.3 5,941 63.9 Some college 504 56.8 6,544 60.3 Has health insurance 595 72.5 8,302 77.9 Ever tested HIV 653 75.4 5,516 48.3

Proportion of all Adults who Received ≥1dose of HBV vaccine, by Age group Include a bar for “total” e.g. all adults 18 years of age and older

Proportion of Adults who Received ≥1dose of HBV vaccine, by Age and Risk Groups * * * * p-value < 0.05

Proportion of High-risk Adults who Received ≥ 1 dose of HBV vaccine, by Age group and Year, NHIS 2004 and 2008 *MMWR 2006, Vol. 55, no. 18

Independent Predictors of Vaccination aOR 95% CI 95 % CI Age group Race / ethnicity 18 – 20 referent --- White, nh 21 – 25 0.6 0.5 - 0.8 Black, nh 0.8 1.7 - 0.9 26 – 30 0.3 0.2 - 0.4 Other, nh 0.9 0.7 - 1.1 31 – 39 0.2 0.2 - 0.3 Hispanic 0.7 - 0.9 41 – 49 0.1 - 0.2 Some college 1.9 1.7 - 2.1 High-risk 1.2 1.0 - 1.4 Has insurance 1.5 1.3 - 1.7 Female Sex 1.3 - 1.6 Ever tested HIV

Limitations Self-reported hepatitis B vaccination status was not verified by a chart review Institutionalized adults were not included in the survey NHIS population (well educated and insured) might not be representative of the general U.S. population

Conclusions Although recommended for vaccination, high risk individuals were no more likely to be vaccinated than low risk individuals Overall, vaccination coverage among high-risk individuals has not changed substantially since 2004

Recommendations Providers should ensure that high-risk persons are offered vaccination Use of evidence-based immunization strategies such as standing orders and patient reminder / recall systems should be considered to increase vaccination Adult immunization registries should be considered to track adult immunizations

Acknowledgements NCHS for collecting the data The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention (CDC) and should not be construed to represent any CDC determination or policy