1. Resources for New Providers of Hepatitis B Vaccination in Alternative Settings Teresa A. Anderson, DDS, MPH National Immunization Conference May 12, 2004

2. Which adults are at increased risk of HBV infection? Health care workers or others with occupational exposure to blood or blood products Men who have sex with men Persons with more than one sex partner in a six-month period Persons diagnosed recently with a sexually transmitted disease (STD)

3. Which adults are at increased risk of HBV infection?... Injection drug users Inmates of long-term correctional facilities Hemodialysis patients and patients with early renal failure before they require hemodialysis Recipients of certain blood products (e.g., hemophiliacs)

4. Which adults are at increased risk of HBV infection?... Staff and residents of institutions or group homes for the developmentally disabled Household members and sex partners of persons with chronic HBV infection Susceptible persons from U.S. populations known to previously or currently have high rates of childhood HBV infection

5. Which adults are at increased risk of HBV infection?... International travelers who will live or work for six or more months in areas with intermediate or high levels of chronic HBV infection

6. How are we doing? Substantial declines in the incidence of acute hepatitis B have occurred among highly vaccinated populations, such as young children and health care workers. However, nearly 80,000 persons become infected with HBV each year in the U.S.

7. High-risk adults–those with multiple sex partners, those with a history of an STD, men who have sex with men (MSM), and injection drug users–still account for more than 75% of new cases of HBV infection each year.

8. How are we doing?... Heterosexual activity is now the predominant source of HBV infection among U.S. adults. Fewer than 1% of persons at risk for sexually transmitted HBV seeking care in the private sector are vaccinated against hepatitis B.

9. How are we doing?... A high prevalence (5%-20%) of HBV infection has been documented among MSM, a group with low rates of hepatitis B immunization (3%-28%). In a study of MSM ages 15-22 years in 7 U.S. metropolitan areas during 1994- 98, only 9% had serologic evidence of hepatitis B vaccination.

10. How are we doing?... Within 5 years of beginning injection drug use, 50%-70% of injection drug users (IDUs) become infected with HBV. In one study, only 13%-25% of IDUs in the U.S. reported being offered hepatitis B vaccination.

11. How are we doing?... Up to 47% of prison inmates have evidence of current or past HBV infection. 12%-39% of all Americans with chronic HBV or HCV infection were released from a correctional facility during the previous year.

12. How are we doing?... Approximately 56% of adults with acute hepatitis B have received care previously in a correctional facility or STD treatment clinic.

13. How can we improve hepatitis B vaccination services to high-risk adults and adolescents?

14. “Integration of services” Vaccinate in STD clinics Vaccinate in family planning clinics Vaccinate in clinics for gay and bisexual men Vaccinate in juvenile correctional facilities Vaccinate in prisons and jails Vaccinate in colleges and schools Vaccinate in clinics for the homeless Vaccinate in harm reduction programs and treatment facilities

15. How? ? ? ? ? ? ? ? ? ? ? ?

16. Resources for New Providers of Hepatitis B Vaccination in Alternative Settings

17. Manuals/Guides Adults Only Vaccination: A Step-by-Step Guide (IAC) Viral Hepatitis and HIV/AIDS Integration (NASTAD) Hepatitis B Immunization in an STD Clinic (County of San Diego) ABC Hepatitis Education for Correctional Officers and Inmates (NCCHC)

18. Adults Only Vaccination: A Step-by-Step Guide (IAC)

19. “Adults Only Vaccination” contents 157-page guide CDC video: “How to Protect Your Vaccine Supply” CA Dept. of Health Services video: “Immunization Techniques: Safe, Effective, Caring” Adult Immunization Record Cards Links to updateable versions of all print resources

20. “Adults Only Vaccination” chapters 1Getting Started 2Setting Up for Vaccination Services 3Vaccine Handling and Storage 4Deciding Whom to Vaccinate 5Administering Vaccines 6Documenting and Related Issues 7Financial Considerations: Paying for Your Vaccination Program

21. “Adults Only Vaccination” ordering information $75, with quantity discounts Text available free online To order or download, go to: www.immunize.org/guide

22. Viral Hepatitis and HIV/AIDS Integration (NASTAD)

23. “Viral Hepatitis and HIV/AIDS Integration” chapters 1Starting up: First steps towards the integration of viral hepatitis into HIV/AIDS/STD programs 2Viral hepatitis in the correctional setting 3Viral Hepatitis and HIV: A primer for community planning groups 4Integrating viral hepatitis services into existing HIV and STD clinics

24. “Viral Hepatitis and HIV/AIDS Integration” Download free at www.nastad.org/%5Cdocuments%5Cpublic% 5CViralHepatitisPrograms%5C200294Startin gUPFirstStepsTowardsthentegrationofViralHe p.pdf

25. Hepatitis B Immunization in an STD Clinic (County of San Diego)

26. “Hepatitis B Immunization in an STD Clinic” contents Facts about HBV infection and the hepatitis B vaccine Getting buy-in The 4 W’s of training: who, what, why, when Patient education Case management Includes numerous forms for clinics to adapt

27. “Hepatitis B Immunization in an STD Clinic” Download free at www.hepprograms.org/std/manual/index.htm

28. ABC Hepatitis Education for Correctional Officers and Inmates (NCCHC)

29. “ABC Hepatitis Education” contents Instructor guide with pointers on the characteristics of adult learners pre- and post-tests to gauge the presentation’s effectiveness lecture notes handouts and resources for students overhead transparencies Includes separate manuals for inmates and officers

30. “ABC Hepatitis Education for Correctional Officers and Inmates” Download free from CDC’s viral hepatitis website: www.cdc.gov/ncidod/diseases/hepatitis/ resource/training/ncchc_man.htm

31. Videos “How to Protect Your Vaccine Supply” (CDC) “Immunization Techniques: Safe, Effective, Caring” (CA Dept. of Health Services)

32. “How to Protect Your Vaccine Supply” Produced in 2004 25 minutes long Single copy available free from CDC Multiple copies available for purchase from IAC

33. “How to Protect Your Vaccine Supply” ordering information To order a single copy free from CDC, go to: www2.cdc.gov/nchstp_od/PIWeb/niporderfor m.asp or call toll-free (800) 232-2522. To order multiple copies from IAC ($15 each with quantity discounts): www.immunize.org/vachandling

34. “Immunization Techniques: Safe, Effective, Caring” Updated in 2001 35 minutes long Includes a “Skills Checklist” Available through IAC or CDLHN

35. “Immunization Techniques: Safe, Effective, Caring” ordering information To order from IAC ($25 each with quantity discounts), go to: www.immunize.org/iztech To order from California Distance Learning Health Network ($25 each with quantity discounts), go to: www.cdlhn.com

36. Websites and web pages CDC’s viral hepatitis website: www.cdc.gov/hepatitis Information about hepatitis B and MSM: www.cdc.gov/ncidod/diseases/hepatitis/msm/i ndex.htm Information about viral hepatitis and injection drug users: www.cdc.gov/idu/hepatitis/index.htm Entire website in Spanish: www.cdc.gov/spanish/enfermedades/hepatitis

37. Websites and web pages IAC’s hepatitis prevention programs website: www.hepprograms.org Information on 94 programs preventing hepatitis A, B, and/or C in high-risk populations Includes links to recommendations, journal articles, organizations, and resources for providers and clients National and local support group section

39. Websites and web pages Vaccines for Children Program website: www.cdc.gov/nip/vfc VFC supplies vaccine for children 18 years and younger who are eligible: Medicaid, uninsured, American Indian or Alaska Native, or underinsured (no vaccine coverage)

40. Websites and web pages American Liver Foundation www.liverfoundation.org Hepatitis B Foundation www.hepb.org Hepatitis Foundation International www.hepfi.org

41. Websites and web pages Gay and Lesbian Medical Association www.glma.org/hepatitis GayHealth.com www.gayhealth.com/hepatitis National Alliance of State and Territorial AIDS Directors www.nastad.org

42. Miscellaneous resources Adult Immunization Record Card Available from IAC www.immunize.org/adultizcards

43. Miscellaneous resources

45. CDC Recommendations Sexually Transmitted Diseases Treatment Guidelines--2002 www.cdc.gov/mmwr/preview/mmwrhtml/rr5106a1.htm Prevention and Control of Infections with Hepatitis Viruses in Correctional Settings www.cdc.gov/mmwr/PDF/rr/rr5201.pdf

46. CDC Recommendations Four Division 'Dear Colleague' letter highlighting the 2002 STD Treatment Guidelines recommendations for MSM www.cdc.gov/ncidod/diseases/hepatitis/msm/dearCol leagueMarch8.pdf General Recommendations on Immunization www.cdc.gov/mmwr/PDF/rr/rr5102.pdf

47. CDC Recommendations Prevention of Hepatitis A Through Active or Passive Immunization ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4812.pdf Adult Immunization Programs in Nontraditional Settings: Quality Standards and Guidance for Program Evaluation ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4901. pdf

48. CDC Recommendations Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the U.S. www.cdc.gov/mmwr/preview/mmwrhtml/00033405.htm National Hepatitis C Prevention Strategy: A Comprehensive Strategy for the Prevention and Control of Hepatitis C Virus Infection and its Consequences www.cdc.gov/ncidod/diseases/hepatitis/c/plan/ index.htm

49. Additional References Achievements in public health: hepatitis B vaccination--United States, 1982-2002. MMWR 51(25):549-552,563, 2002 Incidence and risk factors for acute hepatitis B in the United States, 1982-1998: implications for vaccination programs. J Infect Dis 185:713-19,2002. A review of the case for hepatitis B vaccination of high-risk adults. Am J Med 114: 316-18, 2003. Two decades after vaccine license: hepatitis B immunization & infection among young men who have sex with men. Am J Public Health 91:965- 971,2001.

50. Teresa Asper Anderson, DDS, MPH Consultant, Immunization Action Coalition 1573 Selby Avenue, Suite 234 St. Paul, MN 55104 (651) 647-9009 teresa@immunize.org