1. Knowledge, Attitudes and Practices of IHS Hepatitis A Vaccination Providers, Winter, 1999-2000 Doug Thoroughman, PhD (CDC/IHS) James Cheek, MD, MPH (IHS) Beth Bell, MD (CDC) * * *

2. Background Hepatitis A historically endemic in AI/AN communities Vaccine available 1995 Recommended for AI/AN children Fall, 1996 Disease rates down dramatically Is vaccine causing the decline in disease?

3. Purpose Assess with regard to hepatitis A vaccination: –Current attitudes –Current practices Identify factors inhibiting vaccination Compare results to previous survey Suggest ways to address these factors

4. Methods Survey –Adapted from 1996 survey –10 page –20 minutes to complete Identify contact(s) at all IHS facilities Survey sent September, 1999 Responses collected until January, 2000

5. Sample Characteristics 91 eligible IHS facilities identified 79 (87%) responded Responders represented –Every IHS Area except Alaska and California –Urban, rural, and mixed service units

6. Respondent Characteristics 86% Nurses 54% PHN 32% Clinical Nurse 68% at current facility > 5 years 79% worked in immunizations > 5 years Clinical, preventive, administrative duties evenly distributed

7. Results - Provider Attitudes 41% - HAV is very important public health concern 51% - HAV moderately important > 90% - preschoolers and school-age children in high rate areas should be vaccinated 94% - hepatitis A vaccine should only be given in areas with high rates of hepatitis A 59% - Hepatitis A vaccination has decreased the number of HAV cases seen annually

8. Attitudes (Disagree or strongly disagree) 86% - HAV mild so don’t need vaccination 80% - most HAV is in childhood so no need to vaccinate 79% - adding another vaccine too difficult 70.2% - HAV rates too low to warrant vaccination in their communities 27% - duration of protection uncertain (51% neutral)

9. Practices 94% - giving hepatitis A vaccine –Range: 5% - 99% 91% - standing orders 92% - targeting pre-schoolers 64% - targeting school-age children How long? –42% have been vaccinating > 3 years 53% ~ 1 - 3 years

10. Vaccination sites/methods

11. Coverage Estimates

12. Barriers Percent

13. Factors Related to High Preschool Coverage Estimates * Fisher’s Exact p-value

14. Other Outcomes Examined predictors for: –How important a public health problem HAV was considered –Strongly agreeing with ACIP recommendations for HAV vaccination No significant associations found

15. How have things changed?

16. Limitations Generalizability to all AI/AN populations –Tribal vs. IHS health care providers –Urban Self-report

17. Conclusions Hepatitis A vaccine widely available Provider attitudes positive Wide variety of sites/methods used Coverage below optimum in many areas Provider attitude important predictor of success

18. Recommendations Address barriers –Missed opportunities –Vaccine development (combo vaccines) –Parent education –Provider education Duration of protection Vaccine safety information Accurate/timely reporting of disease rates Head Start –Entry requirements and –Vaccination site

19. Acknowledgements All Hepatitis Contacts from each IHS facility Michelle Bowser - IHS National Program Romeo Caringal - CDC ASPH Intern, Summer 1996