1. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Using Non-Traditional Immunization Settings to Immunize High Risk Adults Against Hepatitis A and B Rose T. Wang, MPH, Patricia N. Hernandez, and Melissa Ely Moore, MPH County of Los Angeles Department of Health Services Immunization Program

2. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM National Burden of Viral Hepatitis Disease  Estimated number of new cases annually –Hepatitis A – 61,000 cases –Hepatitis B – 73,000 cases  Reported cases & incidence in 2003 –Hepatitis A – 7,653 cases / 2.6 per 100,000 population –Hepatitis B – 7,526 cases / 2.6 per 100,000 population Source: National Center for Infectious Diseases, Centers for Disease Control and Prevention. Disease Burden from Viral Hepatitis A, B, and C in the United States.

3. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Healthy People 2010 Goals Hepatitis A  Reduce incidence to 4.5 per 100,000 population  Target high risk groups for vaccination: –Illicit drug users –Men who have sex with men (MSM) –Travelers to HAV endemic countries –Occupational risks –Chronic liver disease Source: National Center for Health Statistics. Healthy People 2010: Volume 1 (2 nd ed)

4. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Healthy People 2010 Goals Hepatitis B  Reduce incidence (by age groups): –2.4 per 100,000 for adults ages 19-24 –5.1 per 100,000 for adults ages 25-39 –3.8 per 100,000 for adults ages 40+  Target high risk groups for vaccination: –Injection drug users (IDU) –Sexually active persons –Men who have sex with men (MSM) –Occupational risks Source: National Center for Health Statistics. Healthy People 2010: Volume 1 (2 nd ed)

5. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Los Angeles County Burden of Disease – Hepatitis A  Incidence = 3.37 per 100,000 population  321 new cases in 2004 –Travel outside of US = 21% –Men who have sex with men (MSM) = 3% –Unknown risk factors = 68%  Incidence by race/ethnicity: –Asians = 4.6, Whites = 3.7, Latinos = 2.1, and African Americans = 1.7 per 100,000 Source: Acute Communicable Disease Control 2004 Annual Morbidity Report. Los Angeles County Department of Health Services. Hepatitis A.

6. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Los Angeles County Burden of Disease – Acute Hepatitis B (non-perinatal)  Incidence = 0.75 per 100,000  72 new cases in 2004 –Multiple sex partners = 28% –Men who have sex with men (MSM) = 21% –Injection drug users = 4% –Unknown risk factors = 50%  Majority of cases among males (2.8:1) Source: Acute Communicable Disease Control 2004 Annual Morbidity Report. Los Angeles County Department of Health Services. Hepatitis B, Acute (Non-perinatal)

7. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Challenges in Reducing Hepatitis A and B in Adults  Lack of funding for adult hepatitis vaccines 1  70% of persons with acute hepatitis B had a missed opportunity for vaccination 2  Most “at risk” population receive healthcare and preventive services in the public sector 1 1.Margolis 2003. “Adult Immunization Update” satellite broadcast. 2.Mast E, Mahoney I, Alter J, Margois S. Hepatitis B vaccination of adolescent and adult high-risk groups in the United States. Vaccine. 1998: 16(suppl): S27-S29.

8. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Pilot Vaccination Project  California Department of Health Services, Immunization Branch Request for Applications –To vaccinate at-risk adults for hepatitis A and hepatitis B  Pilot project period: 01/01/04-12/31/04  Eligible applicants - clinics & organizations that provide health services to at risk adults: –STD clients –Homeless –Persons with history of injection drug use –Persons infected with hepatitis C  Clinics must serve low-income, under-insured or uninsured clients –Men who have sex with men (MSM) –Persons with multiple sex partners

9. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM State vs. Local Health Department Role  California Department of Health Services, Immunization Branch –Released RFA and determined Scope of Work –Reviewed proposals and selected clinics –Allocated and subsidized vaccines –Designed data collection methods & instrument  Los Angeles County Immunization Program –Monitored and liaisoned with selected clinics –Delivered vaccine to clinics –Submitted quarterly reports to CA DHS Immunization Branch

10. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Selected Clinics In Los Angeles  21 clinics –9 STD/HIV Clinics  (3 public health clinics – “DHS”) –10 Primary Care Clinics –2 Drug Treatment Centers  Total vaccine allocation (doses) –Single antigen hepatitis A vaccine(HAV) = 795 –Single antigen hepatitis B vaccine (HBV) = 1,865 –Combination hepatitis A and B vaccine (Twinrix) = 5,560

11. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Vaccine Distribution by Type of Clinic 795 doses1,865 doses5,560 doses

12. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Data Collection  Initial data collection period from January- December 2004  Extended through October 2005 due to low utilization in first 12 months  Aggregate demographics and vaccine usage data reported monthly (Monthly Immunization Record) –Type of vaccine administered –Vaccine dose given –Recipient’s age group –Vaccine received –Vaccine wasted/expired

13. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Monthly Immunization Report

14. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Total Proportion of Vaccine Used Over Year 1 and 2 795 doses1,865 doses5,560 doses *Possible reasons for unaccounted vaccine: not recorded as wasted, expired, or used; not yet expired and not used by clinic

15. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Vaccine Doses Administered By Vaccine and Clinic Type

16. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM First Doses of Vaccine Administered By Age Group and Clinic Type

17. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Estimated Percent of Patients Completing Vaccination Series

18. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Project Evaluation  Email/Telephone/Fax Survey (n = 19) –Project satisfaction –Vaccination start and end dates –Risk groups vaccinated –Promotional methods used –Clinic hours –Barriers to vaccination –Prior experience with vaccinating adults

19. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Evaluation Highlights  Average participation = 17 months  58% (11) of clinics had prior experience vaccinating adults  Project satisfaction –“Very Satisfied” with vaccine delivery –“Satisfied” with number of patients vaccinated & Monthly Immunization Reports –“Neutral” with training received  Overall patients were described as “willing” to be vaccinated

20. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Clinic Sessions of Vaccine Availability * Multiple responses allowed Morning Afternoon Evening MorningAfternoon Evening

21. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Common Risk Groups Vaccinated * Multiple responses allowed

22. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Common Methods to Inform Clients of Vaccine Availability * Multiple responses allowed

23. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Challenges in Immunizing Patients * Multiple responses allowed

24. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Improvement Strategies to Increase Vaccine Uptake * Multiple responses allowed

25. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Caveats  Convenience sample  Small sample size  Limited reliability of self-reported data  Aggregate data  Doses administered is not reliable proxy measure of patients vaccinated  Unknown patient flow in clinics  No comparison group  No data on patient populations’ baseline prevalence of hepatitis A/B infection  Cannot evaluate new infections prevented

26. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Project Challenges  Start up issues in Year 1 –Finding proper vaccine storage units –Insufficient staff training –Staff turn over –Lack of experience administering and storing vaccines –Lack of experience with vaccine accountability  “Hoarding” - Fear of vaccine supply depleted before completing series led providers to stringent definition of high risk  Project coordination within LA DHS

27. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Project Modifications to Increase Doses Administered  Extended vaccine use & monitoring until latest expiration date was reached or vaccine supply exhausted  January 2005 – 5 primary care clinics added to increase vaccine use for HBV  Conducted one-on-one site visits with each provider to ensure proper storage, handling, and administration  Encouraged providers to broaden definition of “high risk” to include any adult

28. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Conclusion  Extending project duration could be worthwhile  Project positively received by clinics & clients  Public health clinics administered most number of doses  High completion rates difficult to achieve in “high risk” adult population –24%, 37% & 43% for Twinrix, HBV, and HAV respectively

29. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Future Recommendations  Collect individual patient data  Plan for start-up issues and allow time for 4- 5 month delay  More training with clinic staff and adopt continuous quality improvement methods  Looser “high risk” criteria  Scope of work requirements should be specific, measurable, and achievable –Ex.: Procedures for recruitment, reminder & recall activities, avoiding missed opportunities

30. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Future Recommendations  Coordinated care & patient follow-up system (e.g. registry) to facilitate patient access to vaccine (not limited to 1 clinic)  Reason for initial visit may be better predictor of patient’s behavior to re-visit clinic = opportunity to administer subsequent doses  Continuous vaccine supply may lead to improved completion rates over time

31. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Rose T. Wang, MPH School-Age Immunization Coordinator Immunization Program 3530 Wilshire Blvd Suite 700 Los Angeles, CA 90010 Phone: 213-351-7800 Fax: 213-351-2780 Website: www.lapublichealth.org/ip/ Email: rwang@ladhs.org