FACTORS ASSOCIATED WITH RECEIPT OF HEPATITIS B VACCINE AMONG HIGH RISK ADULTS NATIONAL HEALTH INTERVIEW SURVEY, 2000 Nidhi Jain MD MPH The topic of my presentation is FACTORS ASSOCIATED WITH RECEIPT OF HEPATITIS B VACCINE AMONG HIGH RISK ADULTS”

Acknowledgements Hussain Yusuf MBBS MPH Pascale Wortley MD MPH Shannon Stokley MPH Gary Euler DrPH Sabrina Walton MSPH James Singleton MD

Objectives Understand factors associated with receipt of hepatitis B vaccine among high risk adults 18-49 years of age Encourage discussion regarding effective strategies to vaccinate this group The objectives of this presentation are to help us understand the factors associated with high-risk adults between 18-49 years of age receiving hepatitis B vaccination. We would also like to encourage any discussion regarding effective strategies we can develop to help vaccinate this group

Background In general, adult vaccination rates are lower than childhood rates Hepatitis B vaccination has been recommended for adults with certain high risk behaviors Hepatitis B vaccination can prevent acute and chronic liver disease Some background on vaccinations and in particular hepatitis B. In general adult vaccination rates are lower than childhood rates of the major immunizations. For hepatitis B in particular, children have been universally recommended to preferably receive vaccination upon birth which has resulted in high coverage rates over the past 10 years. But for adults the recommendations have been made for only certain high-risk groups to be vaccinated. This vaccine has been available since 1982 to help reduce the burden of acute and chronic liver disease in this country. Approximately 20,000 new infections of hepatitis B occur annually with 5,000 deaths resulting from chronic liver disease complications.

Adult high-risk groups Persons with a history of sexually transmitted diseases (STDs) Men who have sex with men Injection drug users (street drugs) Persons with hemophilia or other blood clotting disorders and received factors Household or sexual contacts with Hepatitis B infected persons Who is included in these high-risk adult groups? The most common definitions include adults with the following risk factors or behaviors: Persons with Sexually Transmitted Diseases or STDs Men who have sex with men Persons who use Injection street drugs Persons with hemophilia or blood clotting disorders requiring infusion of factors And household or sexual contacts of persons who are already infected with the hepatitis B virus

Adult high risk groups (cont.) Health Care Workers Heterosexually active persons with multiple partners Immigrants from high endemic areas Others Other high risk groups include Health care workers Heterosexually active persons who have multiple partners And Immigrants from high endemic areas among others

Methods Analysis of National Health Interview Survey (NHIS), 2000 Annual face-to-face survey Non-institutionalized US residents Examines current health indices and health care practices Methods We analyzed the year 2000 version of the National Health Interview Survey or NHIS. This is a face to face survey that is done annually among non-insitutionalized US residents The survey examines current health indices and health care practices of its respondents

Methods (cont.) Criteria for Inclusion in this study Any history of sexually transmitted diseases in past 5 years and/or ever having one or more of the following: History of hemophilia and received blood clotting factors Being a man who has had sex with men Used intravenous street drugs Traded sex for money or drugs Tested positive for Human Immunodeficiency Virus (HIV) Had sexual contact with anyone with any of the above risk factors For our analysis of high risk adults, Certain key questions were asked in the NHIS to all adults. Upon analysis, these questions were used to subgroup our population: This included any person answering yes to : Any history of sexually transmitted diseases in the past 5 years and/or ever having one or more of the following risk factors: History of hemophilia and had received blood clotting factors before Being a man who has had sex with men, Used intravenous street drugs, Traded sex for money or drugs, Tested positive for Human Immunodeficiency Virus (HIV) or Had sexual contact with anyone with any of the above risk factors I would like to stress that the second question is a multi-component question in which we do know which risk factor the person is answering to. They only yes or no if they fall into any of the above risk groups. Additionally, for the final data analysis, we only focused on adults within the age group of 18-49 years old.

Methods (cont.) Weighted analysis with SUDAAN Bivariate analysis using chi-square test Assess significant characteristics associated with receipt of at least one dose of hepatitis B vaccine by high-risk adults 18-49 years old With the NHIS dataset, we did a weighted analysis with SUDAAN. Bivariate analysis was done where chi-square was used to determine significance with a p value <.05 By doing this, we could assess the significant characteristics associated with receipt of at least one dose of hepatitis B vaccine among these high-risk adults between 18-49 years old

Results Of 32,374 respondents, 1091 adults (3%) between 18-49 years old reported high-risk characteristics RESULTS Of the 32,374 respondents to the NHIS, 3% or 1091 adults were included in our analysis for high-risk factors based on their response to the survey

Results (cont.) Only 32.6% of high-risk adults identified by this survey reported ever having received at least one dose of hepatitis B vaccination (n=365) Only 23.0% reported receiving the three-dose series (n=249) Of these individuals, only 32.6% reported ever receiving at least one dose of hepatitis B vaccine. And only 23% reported receiving the complete three dose series

Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o Age group n Weighted % vaccinated 95% CI 18-29 years 409 39.4 (33.8, 45.0) 30-39 years 395 30.6 (25.0, 36.1) 40-49 years 287 25.2 (19.8, 30.7) Now I will discuss the significant factors from the analysis: Here you can see that of the high risk adults, younger adults such as those 18-29 years old, had higher coverage levels. In this table, 39.4% of the 18-29 years old group was vaccinated compared to 30.6% of the 30-39 years old group and only 25% of the 40-49 years old group.

Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o Source of primary care n Weighted % vaccinated 95% CI Has primary care source 900 34.8 (31.2, 38.3) Does not have primary care source 191 21.5 (14.7, 28.3) Having an established source of primary care was also significant where of the high risk adults who had an identified source, almost 35% had received at least one hepatitis B vaccine while of those without a source of care only 21% had been vaccinated at least once

Number of visits in the past year Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o Number of visits in the past year n Weighted % vaccinated 95% CI More than one visit 721 36.1 (32.3, 39.9) Only one visit 169 26.5 (19.0, 34.1) None 201 24.7 (17.2, 32.1) And if one had gone to a clinic for care more than one time in a year, 36% had been vaccinated compared to only 27% who only went once in that year or 25% who did not go at all during the year. I would like to note from this slide that even with adults who had more than one visit, only 36% had ever received a hepatitis vaccine which reflects an abundance of missed opportunities in the clinic.

Ever had pneumococcal vaccine Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o Ever had pneumococcal vaccine n Weighted % vaccinated 95% CI Yes 108 52.0 (39.8, 64.1) No 956 30.7 (27.4, 34.1) Having a pneumococcal vaccine was significantly associated where of the high-risk adults who had ever had a pneumococcal vaccine, 52% had also had a hepatitis B vaccine, while of those who has not received a pneumoccal vaccine, only 30% had had a hepatitis B vaccine

Had current year influenza vaccine n Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o Had current year influenza vaccine n Weighted % vaccinated 95% CI Yes 200 48.4 (39.3, 57.6) No 889 28.9 (25.5, 32.4) Similarly with influenza, if one had had a current year vaccine, 48% also had been vaccinated for hepatitis B at least once, while if one did not have a current year flu shot, then only 29% had a hepatitis B vaccine, too

Had ever had HIV blood test Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o Had ever had HIV blood test n Weighted % vaccinated 95% CI Yes 787 36.5 (32.8, 40.3) No 295 23.7 (18.2, 29.2) Other significant variables in the analysis included that if one was a high risk adult and had had an HIV test, 36% had also had a hepatitis B vaccine compared to 24% of those who had not had an HIV test

Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o Ever donated blood n Weighted % vaccinated 95% CI Yes 326 37.2 (31.2, 43.3) No 765 30.6 (27.0, 34.1) And blood donation was also significant in that of those who had donated blood before, 37% had had a hepatitis B vaccine while if one had not donated before, then only 30% had been vaccinated

Factors not associated with hepatitis B vaccination Gender Race/ethnicity Educational level attained Employment status Income Region living in the US Insurance status (Covered/not covered) Factors that were not associated with hepatitis B vaccination among these high risk adults included the following: Gender Race/ethnicity Educational level attained Employment status Income level Region living in the US And Insurance status such as covered vs. not covered

Conclusion Hepatitis B vaccination rates among high-risk adult groups are overall low Greater efforts are needed to vaccinate this group We need to avoid missed opportunities In conclusion, Hepatitis B vaccination rates are overall low among high risk adult groups And greater efforts are needed to vaccinate this group Most importantly, with these overall low coverage rates, we need to avoid any missed opportunities for vaccination when these people are in the clinic

Conclusions (cont.) Factors associated with receipt of hepatitis B vaccine among high-risk adults include: Having a source of primary care Having more than one clinic visit in a year Having a pneumococcal or current year influenza vaccine Having ever had an HIV test Having ever donated blood From our analysis, certain factors have been determined to be significantly associated with receipt of a hepatitis B vaccination for this high risk group: Having a source of primary care Having more than one clinic visit in a year Having had a pneumococcal or current year influenza vaccine Having had an HIV test ever or having donated blood ever.

Limitations Self-reported information regarding high risk factors Self-reported vaccination status- not provider verified Occupation was not accounted for in assessing vaccination status Health care utilization in the past year does not adequately reflect lifetime receipt of hepatitis B vaccine However, there are Limitations in this analysis that need to be noted Which include The fact that the information is primarily self reported by the respondent regarding their high risk behavior and vaccination status with hepatitis B. There is no provider verification of the information Occupation was not accounted for in assessing vaccination status, such as health care workers who are most likely to have higher rates of coverage due to their jobs, And health care utilization in the past year does not adequately reflect hepatitis B coverage in that there is a possibility of receiving a hepatitis B vaccine at any time during your lifetime

Recommendations Encourage using primary care services for immunizations Regular use of health care (more than once a year) should be emphasized Providers should not forget about older age groups who may be high-risk Recommendations we would like to make from the analysis are the following: Encourage using primary care services for immunizations Encourage regular use of health care services, in that visits should occur more than once a year Providers should be informed to not forget that their older age groups may also be at high risk for hepatitis B and still need vaccination to prevent acute and/or chronic disease

Recommendations (cont.) Investigate the use of non-traditional settings for vaccination—ie. HIV testing centers, blood donation centers and STD clinics to increase coverage levels Use evidence-based strategies to raise coverage levels—such as Client or Provider education within multi-component interventions We should also investigate using nontraditional settings for vaccinating adults for hepatitis B such as HIV testing centers, STD clinics, and even blood donation centers And lastly we should use evidence based strategies to help raise coverage levels, such as client and provider education within multi-component interventions Thank you

Thank you!