1. Integrating Hepatitis Screening and Immunizations in the STD clinic Palm Beach County, Florida National Immunization Conference March 8, 2007 Savita Kumar MD, MSPH Medical Epidemiologist/ Consultant Palm Beach County Health Department

2. Thanks to all Contributors: Maria Delgado BHS David Kowalski Vikas Virkud MD Alina Alonso MD Jean M. Malecki MD MPH Florida Dept of Health, Hepatitis Program

3. Hepatitis Program  Background  Funding & Staffing  Objectives of Program  Community Screening  Case Management  Training & Education  Challenges & Lessons Learned

4. Hepatitis Program: Background CDC Comprehensive Immunization Strategy to eliminate transmission of the Hepatitis B virus in the United States, MMWR,Dec 2006 In Palm Beach County, no public clinics where high risk individuals can be screened for Hepatitis A, B, C disease and receive hepatitis vaccine

5. Hepatitis Program: Funding 2005-20062006-2007 Staffing$25,000$65,000 Lab Testing$25,000 Total$50,000$90,000  Funding provided by FL DOH, Hepatitis Program  Hepatitis Vaccine is provided by the Hepatitis Program

6. Hepatitis Program: Staffing 2005: 1 Full-time Temporary Coordinator 2006: 1 Full-time Program Coordinator 1 Part-time Data EntryClerk

7. Objectives of Program:

8.  Screen for Hepatitis A, B, and C when patients are having blood drawn for Syphilis and HIV at their STD clinic visit  Provide vaccination for Hepatitis A and B at that visit  Post-test counsel patients positive for Hepatitis C and/or Hepatitis B (carrier state) and refer these patients for vaccination and follow up medical care

9. Objectives of Program (con’t)  Case management for positive hepatitis B & C cases by using STD Partner Contact Notification (PCN) model  Ask the case to refer contacts of positive hepatitis B & C patients for hepatitis screening and vaccination (self-referral)  Follow up of patients with reminder for subsequent doses of Hepatitis A and B vaccines to complete their hepatitis series

10. Community Screening Activities  Targeted outreach to high-risk individuals by STD staff includes Hepatitis screening when drawing blood in the field  Organized screenings in coordination with other community partners  Hepatitis support group feedback

11. Community Screening Activities (con’t) Screenings sites: Health events with other CBO’s Grant funded minority communities Screenings for pregnant women Immunization Services Drug Rehabilitation Centers Educational events and fairs

12. Priorities for Case Management 1.Hepatitis C positive patients 2.HbsAg positive patients 3.Patients susceptible for Hepatitis B disease 4.Patients susceptible for Hepatitis A disease (Large illegal immigrant population)

13. Hepatitis-STD Clinic Procedures and Guidelines  Assessment Form  Hepatitis clinic procedures and guidelines  Case Management and Follow-up  Hepatitis database  Input from clinic staff  Feedback to medical providers

14. Training and Education 1.Developed and provided training for all STD & clinic staff, Nurses and MD Hepatitis disease Hepatitis Lab Interpretation Vaccine Schedule Pre and Post test Questionnaire for staff Jeopardy games and case scenarios

15. Training and Education (con’t) 2.Incorporated training into HIV 501(c) course for counselors and providers 3.Incorporated Hepatitis Module with other STD modules for new staff members 4.Community presentations to public and medical providers

16. Screening Results Jan – Dec 2006 1392 # patients Assessed for Hepatitis 941 (68%) # (%) Screened for Hep A, B,and C 61 (6.5%) # (%)Positive for Hepatitis C 10 (1.1%) # (%)Hepatitis B carriers( HbsAg +) 397 (42%) # (%) Immune to Hep A Disease 372 (40%) # (%) Immune to Hep B Disease 570 Doses # Hepatitis A vaccine doses given 574 Doses # Hepatitis B vaccine doses given

17. Screening Results by Race / Ethnicity Jan – Dec 2006 (Cont) Race/ Ethnicity # Tested # HAV % pos # HCV % pos # HbsAg % pos W N-Hisp23455 (23%)31(13%)1 Black389111 (28%)18 (5%)3 Hispanic213159 (75%)6 (3%)1 Haitian6655 (83%)3 (4%)5 All Other2211 (50%)2* (9%)- Total924*391*60*10

18. Screening Results by Age Group Jan – Dec 2006 (Cont) Age Group # Tested # HAV % pos #HCV % pos #HbsAg % pos <15 yrs4--- 15-19 yrs10019 (10%)3 (3%)1 20-29 yrs416158(38%)16 (3.8%)- 30-49 yrs327165(50%)31 (9.5%)6 >50 yrs9455 (58%)11(11.7%)3 Total9413976110

19. Challenges and Lessons Learned

20. 1.Length of time for Hiring and training of Hepatitis Coordinator  From July-Nov 2005 hiring and training hepatitis coordinator on hepatitis disease, vaccines, lab interpretation and STD diseases.  Screening at the STD clinic did not get implemented until November 2005.  In February 2006, Coordinator left the program, STD clinic moved to a new building; screening had to be temporarily stopped from March to July 2006  Other STD staff helped while we established full-time permanent position and hired the person in October 2006

21. Challenges or Lessons Learned (con’t) 2.Patients did not come back for their hepatitis test results  Instituted STD follow-up procedures: 1. Letter 2. Telephone call 3. Field visit  Sent “urgent” letters to patients who had positive results  Sent “reminder” letter to patients who were susceptible for hepatitis A & B and needed hep A or B vaccines

22. Challenge or Lessons Learned (con’t) 3.Response to screening was overwhelming for the resources available.  Modified screening process to high-risk individuals and patients who wanted this service  Instituted procedure for follow up visit to be quick for test results and for giving 2 nd or 3 rd dose of hepatitis vaccine.

23. Contact Info Savita Kumar, MD, MSPH Medical Epidemiologist/Consultant Palm Beach County Health Department 851 Ave “P” Riviera Beach, FL 33404 Tel: 561-803-7354 Savita_kumar@doh.state.fl.us

24. QUESTIONS??? Thank you