National Immunization Conference Nashville 5/2004 Hepatitis A and Hepatitis B Vaccination in High Risk Adults: Florida’s Experience with Integrating Services Accountability, Series Completion, and Early Program Evaluation Sandra W. Roush, MT, MPH National Immunization Conference Nashville 5/2004

Florida: The Sunshine State Escambia Holmes Jackson Santa Rosa H o l m e s S a n t a R o s a J a c k s o n Okaloosa W Walton a l t o n W Washington Nassau a s h i n g o Gadsden G a d s d e n Leon Hamilton N a s s a u Calhoun Jefferson L e o n J e f f e r s o n M Madison a d i s o n H a m i l t o n Duval Liberty B a k Baker e r D u v a l W Wakulla Suwannee a k u l l a Taylor S u w a n n e e Columbia C o l u m b i a Bay T a y l o r Union Clay Gulf Franklin L a Lafayette f a y e t t e U n i o n Bradford C l a y St. John’s Florida: The Sunshine State F r a n k l i n B r a d f o r d S t J o h n s i Gilchrist l c h r i s t Alachua Dixie A l a c h u a Putnam P u t n a m F l a Flagler g l e r Levy M a Marion r i o n V o Volusia l u s i a Citrus C i t r u s Sumter Lake L a k e Seminole u m t e r S e m i n o l e Hernando O r a Orange n g e B r e v a r d Pasco 17+ million population 67 counties ( 9 funded ) Hepatitis A rates 5.89 (2001), 5.32 (2002), and 1.94 (2003) per 100,000 Hepatitis B rates 3.45 (2001), 3.25 (2002), and 3.15 (2003) Estimates indicate over 300,000 Floridians infected with hepatitis C Osceola i Hillsborough l l s b o r o u g h Pinellas Polk O s c e o l a Brevard P o l k I n Indian River d i a n R i v e r Manatee Hardee Okeechobee M a n a t e e H a r d e e O k e e c h o b e e St. Lucie Highlands S t L u c i e Desoto H i g h l a n d s Sarasota r o t a D e S o t o Martin Charlotte C h a r l o t t e G Glades l a d e s Hendry Lee P Palm Beach a l m B e a c h Collier B r Broward o w a r d Monroe Miami- Dade D a d e

Florida’s Hepatitis (A, B, C) Program Providing leadership, policy development, and technical assistance Development of a comprehensive prevention plan Counseling and testing services Vaccination for adults Patient care services Prevention initiatives Allocating state hepatitis resources

Florida’s Statewide High Risk Adult Hepatitis Immunization Program Initial purchase Dec. 2000 with carry over funds 30,120 doses B ($ 700,290) 946 doses A ($ 15,306) Subsequent purchases: state and federal Eligibility: adult high risk (STD, HIV, family planning, jail, outreach, epidemiology, immunization, hepatitis, etc.) Statewide memos March 2001 and Dec. 2002 NO CHARGE TO CHD OR CLIENT Current monthly average for vaccine shipment : 1,175 hepatitis A; 2,163 hepatitis B

Florida Adult Hepatitis Vaccine Management 2000 – 2003 $ 1,828,151 $ 812,289 79,492 Number of Doses 46,470 70,211 40,332 68,974 34,167 * Combined vaccine was also purchased: 2,330 doses ($ 82,374)

CY 2003 Adult Program Hepatitis A Vaccine Accountability* 18,288 total doses required accountability 5,526 doses in CHD refrigerators 1/1/03 12,901 doses distributed 139 doses wasted 17,746 total doses in accounting 13,835 coded/used 3,911 in CHD refrigerators 12/31/03 * 820 doses (4%) unaccounted

CY 2003 Adult Program Hepatitis B Vaccine Accountability* 35,033 total doses required accountability 5,573 doses in CHD refrigerators 1/1/03 29,823 doses distributed 363 doses wasted 34,536 total doses in accounting 29,567 coded/used 4,969 in CHD refrigerators 12/31/03 * 1,499 doses (4%) unaccounted

Adult Hepatitis A Vaccine Used/Coded November 1, 2000 to December 31, 2003 Funded Counties Unfunded Counties Total Doses Used 20,642 13,525 Dose 1 17,593 11,224 Dose 2 3,049 (17%) 2,301 (21 %)

Hepatitis A Vaccine Doses and Series Completion in High Risk Adults: 67 Counties 25% 15% Number of Doses 20%

Hepatitis A Number of Doses and Series Completion in High Risk Adults: Selected Counties CY 2001 CY 2002 CY 2003 Number of Doses

Adult Hepatitis B Vaccine Used/Coded November 1, 2000 to December 31, 2003 Funded Counties Unfunded Counties Total Doses Used 35,598 29,671 Dose 1 19,268 17,072 Dose 2 10,364 (54%) 8,311 (49%) Dose 3 5,966 (58%)* 4,288 (52%)** *Funded Counties 31% hepatitis B series completion during this time period **Unfunded Counties 25% hepatitis B series completion during this time period

Hepatitis B Vaccine Doses and Series Completion Hepatitis B Vaccine Doses and Series Completion* in High Risk Adults: 67 counties 53% 57% 51% 52% Number of Doses 50% 48% *Series Completion: 2001 (24%); 2002 (27%); 2003 (30%)

Hepatitis B Vaccine Doses and Series Completion in High Risk Adults: Selected Counties CY 2002 CY 2001 CY 2003 Number of Doses

Adult Hepatitis Vaccine and Testing Program: Early Program Evaluation Chart review process similar to quality improvement Clients seen Nov 1, 2001- Oct 31, 2002 Demographics, doses received/dates, test results, results received, risk factors, medical/social referral As of 11/6/2003, 1,541 charts reviewed in 11 counties 9 site types (family planning, general, hepatitis, HIV, immunization, outreach, primary care, TB, STD) Randomly selected charts within clinic type Number of charts selected is based on county population contribution

Clients’ Use of Hepatitis A Vaccine November 1, 2001 – October 31, 2002 Dose 1 54 % of lab eligible (228/419) 26 % of risk assessment eligible (341/1309) 72 % of HCV positive (52/72) Dose 2 30 % of lab eligible (125/419) 13 % of risk assessment eligible (175/1309) 49 % of HCV positive (35/72)

Clients’ Use of Hepatitis B Vaccine November 1, 2001 – October 31, 2002 Dose 1 58 % of lab eligible (288/501) 35 % of risk assessment eligible (451/1309) 72 % of HCV positive (52/72) Dose 2 42 % of lab eligible (210/501) 24 % of risk assessment eligible (309/1309) 57 % of HCV positive (41/72) Dose 3 25 % of lab eligible (126/501) 14 % of risk assessment eligible (184/1309) 39% of HCV positive (28/72)

Date Appropriate Hepatitis Vaccination Date Appropriate Hepatitis Vaccination* November 1, 2001 – October 31, 2002 Hepatitis A 25 % of lab eligible (103/419) 12 % of risk assessment eligible (160/1309) 35 % of HCV positive (25/72) Hepatitis B 25 % of lab eligible (123/501) 16 % of risk assessment eligible (205/1309) 31 % of HCV positive (22/72) * Among those starting vaccine

Date-Appropriate Adult Hepatitis A Vaccination by Clinic Site   Date-Appropriate Adult Hepatitis A Vaccination by Clinic Site Clinic Site # Approp.Vaccinated to Date (n=438) # Seen in Clinic(s) % Vaccinated in Clinic(s) Odds Ratio For Vaccination Hepatitis 171 396 43 2.50 (p=<0.05) All other 267 1145 Outreach 24 54 44 2.07 (p=<0.05) 414 1487 HIV 56 242 23 0.72 (p=<0.05) 382 1299 Immunization 42 214 20 0.57 (p=<0.05) 1327 PC/Gen, TB, FP 64 323 0.56 (p=<0.05) 374 1218 STD 81 312 26 0.86 (p=<0.28) 357 1229

Date-Appropriate Adult Hepatitis B Vaccination by Clinic Site   Date-Appropriate Adult Hepatitis B Vaccination by Clinic Site Clinic Site # Approp.Vaccinated to Date (n=438) # Seen in Clinic(s) % Vaccinated in Clinic(s) Odds Ratio For Vaccination Hepatitis 187 396 47 3.39 (p=<0.05) All other 239 Outreach 39 54 72 3.64 (p=<0.05) 387 HIV 242 19 0.59 (p=<0.05) 379 Immunization 214 34 1.39 (p=<0.05) 354 PC/Gen, TB, FP 43 323 13 0.33 (p=<0.05) 383 1218 STD 38 312 12 0.30 (p=<0.05) 388

Hepatitis Testing for Florida Adults at Risk Statewide ABC panel (“chronic panel”) Hepatitis A (anti-HAV total) added 2/9/04 Hepatitis B (HBsAg, HBsAb, HBcAb) HCV Anti-HCV with signal-to-cut-off ratio Polymerase chain reaction (PCR) and/or recombinant immunoassay (RIBA™) Pricing considerations Medicaid Signal-to-cut-off ratio

Florida Chronic Hepatitis Testing Program: Results Summary* Positive No. (%) Negative Missing/Other HBsAg 288 (1) 25,012 (95) 941 (4) HBsAb 6,632 (25) 18,757 (72) 852 (3) HBcAb 3,213 (12) 21,715 (83) 1,313 (5) HCV-EIA 2,928 (11) 22,415 (85) 898 (4) Number (percent) based on n=26,241 “chronic panels” Jan. 2001 – Dec. 2003

Hepatitis Integration Guidance

Next Steps: Florida’s Adult Hepatitis A and B Immunization Program Vaccine accountability mechanisms Coverage assessment Evaluation Feasibility Cost effectiveness/efficiency Expand to additional clinics and other sites Ensure a reliable vaccine supply