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

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.

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)

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 –5.1 per 100,000 for adults ages –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)

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.

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)

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 “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.

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

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

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

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Vaccine Distribution by Type of Clinic 795 doses1,865 doses5,560 doses

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

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Monthly Immunization Report

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Total Proportion of Vaccine Used Over Year 1 and 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

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Vaccine Doses Administered By Vaccine and Clinic Type

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM First Doses of Vaccine Administered By Age Group and Clinic Type

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Estimated Percent of Patients Completing Vaccination Series

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Project Evaluation  /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

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

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Clinic Sessions of Vaccine Availability * Multiple responses allowed Morning Afternoon Evening MorningAfternoon Evening

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Common Risk Groups Vaccinated * Multiple responses allowed

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Common Methods to Inform Clients of Vaccine Availability * Multiple responses allowed

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Challenges in Immunizing Patients * Multiple responses allowed

County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Improvement Strategies to Increase Vaccine Uptake * Multiple responses allowed

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

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

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

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

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

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

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 Phone: Fax: Website: