1. CDC’s Adult Hepatitis B Vaccination Initiative
Hope King MSPH,
Lead Health Scientist
Jacqueline Avery, MPH, &
Health Scientist
Carol Friedman DO
Assoc. Dir. Adult Immunization
Centers for Disease Control and Prevention
The findings and conclusion in this report are those of the author (s) and do not necessarily
represent the official position of the Centers for Disease Control and Prevention

2. Outline Background on Hepatitis B virus infection
Rationale for new ACIP adult hepatitis B vaccine recommendations
Adult Hepatitis B Vaccination Initiative
Data from Year 1 and Year 2
5 high performing jurisdictions

3. Hepatitis B Virus Infection
Transmission
Main risk factors
# of new infections
Chronic infection
# of chronic infections
# of annual deaths
Vaccine
Percutaneous, mucosal
Multiple sex partners, MSM, IDU, sexual and household contacts, infants born to infected mother
43, 000 in 2007
Among unimmunized person, chronic infection occurs in >90% of infants, 25%-50% of children 1-5, and 6%-10% of older children and adults
800, million in 2007
2,000-4,000 in 2007
Yes
Hepatitis B virus is transmitted by percutaneous or mucosal exposure to the blood or body fluids of an infected person, most often through injection-drug use (IDU), sexual contact with an infected person, or contact from an infected mother to her infant during delivery. Transmission of hepatitis B virus also occurs in settings involving nonsexual interpersonal contact for an extended period (e.g., among household contacts of a person with chronic Hepatitis B virus infection) (CDC, 2009). Of an estimated 43, 000 new hepatitis B virus infection in 2007, 70% were attributable to injection drug use and high-risk sexual activity. Also, up to 1.4 million people may have chronic hepatitis B, many of whom are unaware of their infection .
Because of asymptomatic nature of chronic hepatitis B, most people who have it are unaware until they have symptoms of liver cancer or liver disease many years later, which results in deaths per year

4. Reported Acute Hepatitis B Incidence By Age Group: United States, 1990-2005
≥20 years
96% decline
76% decline
12-19 years
Cases per 100,000
35% decline
<12 years
Hepatitis B vaccine has been successfully integrated into the childhood vaccination schedule, contributing to a 96% decline in the incidence of acute Hepatitis B in children and adolescents. Currently, approximately 95% of new HBV infections occur among adults, and unvaccinated adults with behavioral risk factors or who are household contacts or sex partners of HBV-infected persons remain at risk.
Year
Source: National Notifiable Diseases Surveillance System, CDC

5. Reported Acute Hepatitis B United States, 1985-2007
Universal vaccination of infants recommended
>82% decline in incidence
2007 rate =1.5/100,000
Incidence in the United States
In 2007 the number of reported cases of hepatitis B was 4, 519. The overall incidence rate of hepatitis B was 1.5 cases per 100,000 population. This rate is the lowest recorded, and it represents a decline of 82% since 1990.
Source: National Notifiable Diseases Surveillance System (NNDSS) 5

6. Source: Sentinel Counties Study of Viral Hepatitis (n=760)
Prior Opportunities For Vaccination Among Patients With Acute Hepatitis B,
Prior Opportunity for Vaccination %
History of incarceration
40%
History of STD treatment
39%
History of drug treatment
22%
Any of the above
61%
Many opportunities exist to prevent HIV and viral hepatitis infections in public health settings, such as HIV counseling and testing sites, sexually transmitted disease clinics, substance abuse treatment programs, jails and prisons..
Ongoing failure to prevent hepatitis B virus infection may be attributable to missed vaccination opportunities in public health clinics.
In a study that investigated acute hepatitis B virus infections, an estimated 61% had a missed opportunity, 39% had been treated for an STD, 40% had been incarcerated, and 22% had been in a drug treatment, but did not receive vaccination
Source: Sentinel Counties Study of Viral Hepatitis (n=760)

7. Hepatitis B Vaccine Coverage Lowest for Persons with Behavioral Risks
Children (19-35 mos.) %
Adolescents age 13 yrs %
Adults –(self reported, NHIS) %
Adults at risk for infection
Occupationally-exposed workers 75%
Dialysis patients 56%
Men who have sex with men %
Injection drug users %
STD clinic clients %

8. Why Low Vaccination Coverage ?
Cost of hepatitis B vaccine is a major BARRIER ($150 FOR THREE DOSES)
However THE BENFITS out ways the COST:
The vaccine is safe and effective
30%-55% after 1 dose
75% after 2 doses
>90% after 3 doses
Hepatitis B vaccine requires three doses over a 6-month time period and is costly (approximately $150 for three dose series).
However the benefits out ways the Cost of not vaccinating adults. Approximately 2-4,000 deaths from acute or chronic hepatitis B virus infection occur each year, and hepatitis B virus infections result in an estimated $658 million in medical costs and lost wages annually

9. Strategy to Eliminate HBV Transmission
Prevent perinatal HBV transmission
Universal infant vaccination
Catch-up vaccination of all children and adolescents <19 years
Vaccination of adults in high risk groups
Because a large burden of disease was occurring as a result of HBV transmission in all age groups, in 1991, ACIP recommended a comprehensive immunization strategy that was designed to eliminate transmission in all age groups. This strategy includes:

10. Timeline: 2006
In December 2006, CDC and ACIP published new guidelines that recommend vaccinating all susceptible adults in care settings where clients are likely to be at risk for HBV infection.

11. New Recommendations

12. Hepatitis B Vaccine Recommendations for Adults
HepB vaccine recommended for:
all unvaccinated adults at risk
all adults seeking protection (acknowledgment of specific risk factor not required)
Vaccination strategies for
Settings w/high proportion of at risk adults

13. Settings where hepatitis B vaccination is recommended for all clients:
STD treatment facilities
HIV testing/treatment facilities
Drug abuse treatment/prevention facilities
Correctional facilities
Facilities targeting services to MSM/IDU
Chronic hemodialysis facilities and endstage renal disease programs
Institutions and nonresidential daycare facilities for developmentally disabled persons
Setting based recommendations are new.
These recommendations are intended to reduce barriers to vaccinating at risk populations
Advisory Committee on Immunization Practices

14. Timeline: October 2006
Fenton/Schuchat ‘Dear Colleague’ Letter

15. Fenton/Schuchat ‘Program Manager’ Letter October 10, 2006

16. Fenton/Schuchat ‘Dear Colleague’ Letter
Hasten elimination
of HBV
transmission
Implement ACIP recommendations
Encourage states to use Section 317 funds
Convene Workgroup
Integrate and Collaborate
The purpose of the letter was to encourage state and local immunization programs to consider using section 317 funds to increase vaccination coverage for adults at risk for HBV infection. Secondly CDC encourage collaboration among immunization, STD, HIV, and viral hepatitis prevention programs to define targeted populations, vaccination settings, number of vaccine doses needed, and responsibilities of the participating programs. Subsequent development of plans yielded a 41% increase in hepatitis B vaccine purchase in FT 2007
Hasten elimination of HBV transmission
Encourage states to use Section 317 funds
Implement ACIP recommendations
Convene to develop a collaborative plan
Develop Action Plan
Collaborate
Develop Action Plan

17. Timeline: October 2007
In October 2007, CDC launched the Adult Hepatitis B Vaccination Initiative, which provided Section 317 funds for state and local health departments to purchase hepatitis B vaccine only
No funds for infrastructure cost (e.g., staff, imm registries, supplies, etc.).

18. Goals
Hasten the elimination of hepatitis B disease by vaccinating at-risk adults in public health venues in which CDC and ACIP recommend that all clients should be vaccinated

19. Hepatitis B Vaccine Initiative Funding
52 M over the last three years
$20M to 51 grantees in 07-08
$16M to 48 grantees in 08-09
$16M to 46 grantees in 09-10 19

20. Hepatitis B Vaccination Initiative Venue Settings24 24 9 10 32 16 16 20 48 40 79 52
57 (MA) 15 76
20 (RI) 63
CHI
56 (CT) 15
145 GU 27 21
279
1 (NYC) 2
115 74
142
22 (NJ) MH 38 1 14
8 (DE)
115
108 14
85 (MD)
FSM 4 76
155 PW 21
194
10 (DC ) 5 74 8 3 12 13 82 44
241 20
States that never participated
Participants over 2 years
5 High performing states
101 14 59 PR 9
Total Number of Sites = 3,024 VI
48 states
3 cities (Chicago , NYC, & DC)
5 Territories (Micronesia, Guam, Puerto Rico, Marshall Islands, & Palau) 20

21. Hepatitis B Vaccine Initiative (Nov. 1, 2007 – Dec. 31, 2009)
Setting
Participating Venues
Venues Reporting
Total Doses Ordered
Total Doses Administered
STD Clinics
588
328
205,846
167,476
Jails
179 76
86,560
59,334
SEP 22 8
7,708
3,212
Primary Care
497
173
51,268
25,649
HIV C&T 97 51
11,943
8,868
Prisons
174 82
140,366
82,547
SA Treatment
197 62
46,244
27,519
Local HD
1,020
416
301,716
220,780
Other
250 64
30,917
22,740
Total*
3,024
1,260
882,568
618,125
Of 3, 024 venues enrolled, 1, 260 (42%) reported administering vaccine. Of the 800, 000 plus vaccine doses ordered, 618, 125 (70%) were administered from Nov 1, Dec 31, 2009.
Overall 86% or 530, 137 doses of vaccine was administered in LHD, STD clinics, jails and prisons
We believe this level of participation and engagement during the first quarter is remarkable considering the work needed to increase vaccination particularly in new vaccination sites and because the initiative does not cover infrastructure costs.
* Data does not contain reports from Marshall Islands 21

22. What Settings are Doing Well? (Nov. 1, 2007 – Dec. 31, 2009)
Certain venue types were able to administer more vaccine and use a greater proportion of the vaccine they ordered, in particular local health departments over (220, 780 or 73%), STD clinics (167, 476, 81%), and correctional facilities
Other venue types that provided less vaccine also administered lower proportions of the vaccine they ordered including syringe exchange programs and primary care clinics (8,232, 28%).
Total Number of Doses Administered = 618,125

23. Vaccine Administration: Yr 1 Vs Yr 2 (November 1, 2007 – December 31, 2009)
There was a 24% increase in vaccine administered from year 1 to year 2. Also, with the exception of jails every venue type increased the amount of vaccine administered from year 1 to year 2.
Doses Administered Year 1 = 275, 445
Doses Administered Year 2 = 342,680
24% Increase

24. 5 High Performing States (Nov. 1, 2007 – Dec. 31, 2009)
Setting
California
Florida
North Carolina
Ohio
Texas
5 High Performing States
STD Clinics
19,311
57,391 (100%)
11,644
88,346 (53%)
Jails
6,720
4,421
5,977
17,118
SEP
1,038
Primary Care
4,444
379
400
1,013
6,236
HIV C&T 69
697
766
Prisons
1,470
259
6,022
7,751
SA Treatment
1,984
1,866
2,047
5,897
Local HD
17,834
52,141
5,833
82,701
158,509 (72%)
Other
525
1,076
1,488
3,089
Total*
53,395
59,883
58,050
34,721
288,750 (47%)
Nationally, five of the 56 jurisdictions administered 47% or 288, 750 of hepatitis B vaccine to adults. Among the five states, 72% of the doses were administered in local health departments and 53% of the doses in STD clinics. Lastly the range was 47, 980 doses.
The range was 47, 980 doses.
* Data does not contain reports from Marshall Islands 24

25. Florida Vaccine Administered (Nov. 1, 2007 – Dec. 31, 2009)
Target Population: MSM,IDUs, incarcerated persons
Primary Setting (s): LHDs and Jails
Trained Staff
Written Protocols and Standing Orders
Promotional Activities

26. Florida Vaccine Administered (Nov. 1, 2007 – Dec. 31, 2009)
For Florida an increase of 36% was found in doses administered in baseline period to year 1
~ 28, 927 Year 1
~ 30, 956 Year 2
~36 % increase

27. North Carolina Vaccine Administered (Nov. 1, 2007 – Dec. 31, 2009)
Target Population: MSM, IDU, HRH, incarcerated, Hep C +, & HIV positive
Primary Setting (s): STD clinic
Written Protocols and Standing Orders
Trained Staff
Promotional Activities
For North Carolina an increase of 16% was found from the baseline period to year 1.

28. North Carolina Vaccine Administered (Nov. 1, 2007 – Dec. 31, 2009)
For North Carolina an increase of 16% was found from the baseline period to year 1.
~ 31, 747 Year 1
~ 26, 303 Year 2
~16 % increase

29. Lessons Learned
Hepatitis vaccine, when supplied at no cost, can be delivered to a significant number of unvaccinated high risk adults in a variety of settings as part of existing clinical activities.
Institutional commitment and a local champion have increased vaccination efforts
Trained and knowledgably staff who recommend vaccination are contributing to the reduction of hepatitis B among high-risk adults

30. Lessons Learned
Instituting standing orders and protocols have been a significant key
Integrated delivery of vaccine with other services has enhanced program collaboration and service integration
Infrastructure cost was not component of funding, thus vaccination coverage rates and series completion rates are limited ~ additional resources are needed to track vaccine completion rates

31. Summary
There is a time limited opportunity to accelerate elimination of HBV transmission
Hepatitis B vaccination of at risk adults represents one the greatest challenges to the goal of eliminating hepatitis B virus transmission in the United States.
In order to meet the current Healthy People 2010 objective to reduce acute hepatitis B cases by 75-90% among high risk adults, more aggressive hepatitis B vaccination initiatives are needed.

32. Summary
Therefore we must endeavor to reach unvaccinated adults by empowering public programs with resources to provide counseling, testing, vaccination, and follow up services for viral hepatitis.
This will protect vulnerable adults from hepatitis B virus infection, as well as protect transmission to others

33. Acknowledgements 317 Initiative Managers
48 states, 3 cities, 5 territories
Hepatitis B Vaccination CDC