Hepatitis B Vaccination Assessment Adults Aged 18-64 Years National Health Interview Survey, 2000 Gary L. Euler, DrPH1, Hussain Yusuf, MBBS2, Shannon Stokley, MPH2, Sabrina E. Walton, MSPH3, James A. Singleton, MS1 1Viral Vaccine-Preventable Diseases Branch, Epidemiology and Surveillance Division, NIP, CDC 2Health Services Research and Evaluation Branch, Immunization Services Division, NIP, CDC 3DynCorp, A CSC Company

Acute Hepatitis B in the U.S. 81,000 estimated cases of acute hepatitis B in the U.S., 2000 Most occurred in adults in known risk groups Most had missed opportunities for vaccination 22,000 figure provided 12/05/02 by Annemarie Wasley, DVH

Adult Risk Groups for Hepatitis B – 1 Persons with history of STD Persons with multiple sex partners (>1 partner / 6 months) Men who have sex with men Injecting drug users Incarcerated persons Immigrants from countries with HBV prevalence ≥2% Hepatitis B vaccination has been recommended for persons with risk factors for HBV infection since the vaccine was licensed in 1981

Adult Risk Groups for Hepatitis B – 2 Household and sex contacts of HBV-infected persons Healthcare and public safety workers who have exposure to blood in the workplace Hemodialysis patients Recipients of clotting-factor concentrates Hepatitis B vaccination has been recommended for persons with risk factors for HBV infection since the vaccine was licensed in 1981

Healthy People 2000 & 2010 Objectives for Hepatitis B Vaccination of High Risk Adults Occupationally exposed—90% Men who have sex with men—50% IDUs—50% 2010 Occupationally exposed—98% Men who have sex with men—60% Long-term hemodialysis patients—90%

National Health Interview Survey (NHIS), 2000 Conducted by the National Center for Health Statistics, CDC Continuous operation since 1957 Data collected through household face-to-face interviews of the U.S. resident civilian noninstitutionalized population Primary source of general health information

NHIS Design – 1 Stratified multistage sampling One sample adult and one sample child (if present) are interviewed in each family Used SUDAAN 8.0 to analyze the weighted data.

NHIS Design – 2 All responses are self-reported and are not provider verified. A respondent weight is assigned that adjusts for the probability of being sampled and for non-response to provide unbiased and design-based estimates of any U.S. target population. Used SUDAAN 8.0 to analyze the weighted data.

Hepatitis B Vaccination Questions Have you EVER received the hepatitis B vaccine? Yes/No/Refused/Don’t know If Yes: Did you receive at least 3 doses, or less than 3 doses? Received at least 3 doses/Received less than 3 doses/Refused/Don’t know Used SUDAAN 8.0 to analyze the weighted data.

Demographic Variables Included in this Analysis Gender, age, race/ethnicity, education Marital status, family income, family size City size (MSA), census region Health insurance

Lifestyle Variables Included in this Analysis – 1 Occupation, composite risk group* Chances of getting HIV, ever tested for HIV, main reason for HIV test STD, where checked for STD Usual place of routine care type, medical record source (preventive vs sick care), time since last talked to a health professional & number of visits in past 12 months. * Men who have sex with men, persons who ever traded sex for money or drugs, IVDUs, HIV positives, hemophiliacs who have received clotting factor concentrates, and their sex-partners.

Lifestyle Variables Included in this Analysis – 2 Lived with someone with hepatitis Family hepatitis history Lived with someone with liver cancer Family liver cancer history Smoking status, alcohol drinking status Physical activity, BMI

Risk Status Strata Aged 18-64 Years n=26,194 Occupational risk n=1,714 Healthcare, police and fire Behavioral risk (excluding above) n=1,460 Men who have sex with men, IVDUs, HIV positives, clotting factor recipients, traders of sex for money or drugs, and sex-partners; STD patients, and those reporting high or medium chance of getting HIV. Possible risk (excluding above) n=8,703 Ever tested for HIV, ever lived with someone with hepatitis, or API No identified risk n=14,317

Hepatitis B Vaccination by Risk Groups, Aged 18-64 Years, NHIS, 2000 Sample Size Hepatitis B Vaccination Dose 1 Rates % (95% CI) Occupational 1,714 74 (71-76) Behavioral 1,460 30 (27-33) Possible 8,703 27 (26-28) No Identified 14,317 16 (15-17)

Significant Associations Found

Hepatitis B Vaccination by Risk Status and Gender, Aged 18-64 Years, NHIS, 2000 (n=26,194) * * * Male vs. Female p<0.05 *

Hepatitis B Vaccination by Risk Status and Age, Aged 18-64 Years, NHIS, 2000 (n=26,194) * * * Age group vs. 50-64 y p<0.05 * *

Hepatitis B Vaccination by Risk Status & R/E, Aged 18-64 Years, NHIS, 2000 (n=26,194) * R/E group vs. White p<0.05 * * * *

Hepatitis B Vaccination by Risk Status & Education, Aged 18-64 Years, NHIS, 2000 (n=26,194) * * * * Group vs. <HS p<0.05 *

Hepatitis B Vaccination by Risk Status & Marital Status, Aged 18-64 Years, NHIS, 2000 (n=26,194) * Group vs. Never married p<0.05 * * *

Hepatitis B Vaccination by Risk Status & Time Since Last Saw Provider, Aged 18-64 Years, NHIS, 2000 (n=26,194) 95% CI * * * * ≤ 2 years vs. 2 years p<0.05

Adults Less Likely to Receive Hepatitis B Vaccination Males (except in behavior risk group) Age 35+ (except in occupational risk group) Whites vs. blacks in possible risk group Hispanics & blacks vs. whites in occupational risk group Educational level of less than high school Never married (except in occupational risk group) Not seen a provider in over 2 years (except in occupational risk group) No HBV risk

Have Unvaccinated Adults at Risk for HBV Infection had the Opportunity for Protection? Of 30,007 adults, 23,807 (79.3%) had not received hepatitis B vaccine. Of these 23,807, 7881 (33.1%) had a risk factor.* Of these 7881, 91.6% had talked to a provider in the last 24 months; 79.4% visited the MD in last 12 months, 62.4% 2-10+ times * Health care, police or fire occupation; ever had a STD other than HIV; ever tested for HIV; high or medium chance of getting HIV; ever lived with someone with hepatitis or liver cancer; men who have sex with men, persons who ever traded sex for money or drugs, IVDUs, HIV positives, hemophiliacs who have received clotting factor concentrates, and those who have had sex with any in these groups.

Limitations – 1 NHIS 2000 does not directly measure progress toward HP 2000 and 2010 objectives for hepatitis B vaccination—among adults who are occupationally exposed, among men who have sex with men, IDU, or among chronic hemodialysis patients.

Limitations – 2 Non-validated data We do not know the quality of recall information related to adult hepatitis B vaccination

Conclusions – 1 Hepatitis B vaccination rates among adults at risk for HBV infection are low. Recent provider contact was associated with higher likelihood of vaccination.

Conclusions – 2 Adults at risk have seen providers in the past 24 months but rarely have utilized the opportunity to be vaccinated. More specific data sources are needed to measure progress toward Healthy People objectives.

Recommendations – 1 Providers need to identify adults at risk for HBV infection (tools may be needed) and offer hepatitis B vaccination to them. Health education and motivation to ensure hepatitis B vaccination as indicated should be provided to both adults at risk and their providers.

Recommendations – 2 Hepatitis B vaccine should be offered to all susceptible patients in STD, family planning, and drug treatment clinics, HIV prevention sites and correctional facilities.