1. 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

2. 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 (2003) per 100,000
Hepatitis B rates 3.45 (2001), 3.25 (2002), and (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

3. 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

4. Florida’s Statewide High Risk Adult Hepatitis Immunization Program
Initial purchase Dec 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

5. 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)

6. 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

7. 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

8. 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 %)

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

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

11. 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

12. 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: (24%); 2002 (27%); 2003 (30%)

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

14. Adult Hepatitis Vaccine and Testing Program: Early Program Evaluation
Chart review process similar to quality improvement
Clients seen Nov 1, 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

15. 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)

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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 – Dec. 2003

22. Hepatitis Integration Guidance

23. 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