1. Hepatitis A Vaccination Rates in American Indians Living in the Southwestern United States, 2000/2001 National Immunization Conference April 29 – May 2, 2001 Doug Thoroughman, Amy Groom, Stephanie Bailek, Diana Hu, Stephani Adams, James Cheek, Beth Bell

2. Background Hepatitis A in American Indians –Endemic –Erupting –Eradicated? Vaccination –1995 licensed –1996 recommended –Now? –Vaccination Surveys

3. Methods Two types of survey –Coverage 8 IHS facilities Random sample Children born between 1993 – 1997 90% confident within 5% of true pop. values All rural setting –Analysis complete

4. Methods (continued) Two types of survey –Quality Assurance 13 Tribal facilities Urban and rural settings Children born between 1994 – 1998 Random sample (often all eligible children) 90% confident within 5% of true pop. Values –Analysis in process

5. Data Abstraction Demographics –Name, DOB, HRN, community, gender Date of most recent visit Vaccination dates –Hepatitis A –DTP –MMR

6. Sample Characteristics CharacteristicIHSTribal Number Surveyed1,9561,622 Percent Rural100%66% Percent Amer. Indian100%80% Age Breakdown (%) 3 year-olds 4 year-olds 5 year-olds 6 year-olds 430 (22%) 464 (24%) 510 (26%) 552 (28%) 396 (24%) 400 (25%) 386 (24%) 440 (27%)

7. Hepatitis A Vaccination Coverage IHS Facilities –78.6% received at least one dose Ranged from 73.7% - 82.6% Highest one-dose coverage – 6 year-olds –52.7% completed series (2 doses) –24.5% received 1 st dose by 27 months Tribal Facilities –40.8% received at least one dose –15.2% completed series (2 doses)

8. DTP and MMR IHS Facilities –80.5% received 4 doses DTP by 24 months –68.3% (of those eligible) received 5 th dose DTP –87.7% received 1 MMR by 24 months –71.4% (of those eligible) received 2 nd MMR Tribal Facilities –84.5% received 4 doses of DTP (in total) –89.6% received 1 MMR (in total) –Lower coverage expected at 24 months

9. Completion of Hepatitis A Vaccine – Relationship to Other Vaccines In IHS facilities only: Children who received 4th dose of DTP by 24 months more likely to complete hepatitis A vaccination series Children who received 1st dose of MMR by 24 months more likely to complete hepatitis A vaccination series

10. On-time Coverage* *Percent with first dose of hepatitis A vaccine by 27 months, IHS facilities only. Percent

11. On-time Coverage* * Percent with first dose of hepatitis A vaccine by 27 months, IHS facilities only. Percent

12. Limitations IHS Facilities –Only children known to IHS system How many live here but are not known? Could overestimate coverage –Vaccination info may be incomplete Vaccinations given off-reservation Could underestimate coverage Tribal Facilities –True coverage not possible –Vaccination info may be incomplete Vaccinations given at non-tribal providers Could underestimate coverage

13. Take Home Messages Good progress in instituting Hepatitis A vaccination in IHS setting Tribal health care setting catching up On-time coverage improving each year Hepatitis A vaccination lagging behind DTP and MMR Protection not adequate without higher 2 nd dose coverage

14. Recommendations Increase provider awareness about importance of hepatitis A vaccine Schedule routine clinic visits after 2 year birthday Add standing orders to ER and clinic forms Expand PHN responsibilities to include monitoring of hepatitis A vaccine series completion Provide training to CHRs to increase community and parent awareness

15. Acknowledgements Cheryl Mason, MPH Jennifer Daniels, MPH Vanessa El Harrar, MD Agatha Norwood, BS All the dedicated health care professionals at the surveyed facilities who made this project possible: Medical Records, Public Health Nursing Immunization Coordinators, Chief Medical Officers