1. FACTORS ASSOCIATED WITH RECEIPT OF HEPATITIS B VACCINE AMONG HIGH RISK ADULTS NATIONAL HEALTH INTERVIEW SURVEY, Nidhi Jain MD MPH
The topic of my presentation is
FACTORS ASSOCIATED WITH RECEIPT OF HEPATITIS B VACCINE AMONG HIGH RISK ADULTS”

2. Acknowledgements Hussain Yusuf MBBS MPH Pascale Wortley MD MPH
Shannon Stokley MPH
Gary Euler DrPH
Sabrina Walton MSPH
James Singleton MD

3. Objectives
Understand factors associated with receipt of hepatitis B vaccine among high risk adults years of age
Encourage discussion regarding effective strategies to vaccinate this group
The objectives of this presentation are to help us understand the factors associated with high-risk adults between years of age receiving hepatitis B vaccination. We would also like to encourage any discussion regarding effective strategies we can develop to help vaccinate this group

4. Background
In general, adult vaccination rates are lower than childhood rates
Hepatitis B vaccination has been recommended for adults with certain high risk behaviors
Hepatitis B vaccination can prevent acute and chronic liver disease
Some background on vaccinations and in particular hepatitis B.
In general adult vaccination rates are lower than childhood rates of the major immunizations.
For hepatitis B in particular, children have been universally recommended to preferably receive vaccination upon birth which has resulted in high coverage rates over the past 10 years. But for adults the recommendations have been made for only certain high-risk groups to be vaccinated.
This vaccine has been available since 1982 to help reduce the burden of acute and chronic liver disease in this country. Approximately 20,000 new infections of hepatitis B occur annually with 5,000 deaths resulting from chronic liver disease complications.

5. Adult high-risk groups
Persons with a history of sexually transmitted diseases (STDs)
Men who have sex with men
Injection drug users (street drugs)
Persons with hemophilia or other blood clotting disorders and received factors
Household or sexual contacts with Hepatitis B infected persons
Who is included in these high-risk adult groups?
The most common definitions include adults with the following risk factors or behaviors:
Persons with Sexually Transmitted Diseases or STDs
Men who have sex with men
Persons who use Injection street drugs
Persons with hemophilia or blood clotting disorders requiring infusion of factors
And household or sexual contacts of persons who are already infected with the hepatitis B virus

6. Adult high risk groups (cont.)
Health Care Workers
Heterosexually active persons with multiple partners
Immigrants from high endemic areas
Others
Other high risk groups include
Health care workers
Heterosexually active persons who have multiple partners
And Immigrants from high endemic areas
among others

7. Methods Analysis of National Health Interview Survey (NHIS), 2000
Annual face-to-face survey
Non-institutionalized US residents
Examines current health indices and health care practices
Methods
We analyzed the year 2000 version of the National Health Interview Survey or NHIS. This is a face to face survey that is done annually among non-insitutionalized US residents
The survey examines current health indices and health care practices of its respondents

8. Methods (cont.) Criteria for Inclusion in this study
Any history of sexually transmitted diseases in past 5 years
and/or ever having one or more of the following:
History of hemophilia and received blood clotting factors
Being a man who has had sex with men
Used intravenous street drugs
Traded sex for money or drugs
Tested positive for Human Immunodeficiency Virus (HIV)
Had sexual contact with anyone with any of the above risk factors
For our analysis of high risk adults,
Certain key questions were asked in the NHIS to all adults. Upon analysis, these questions were used to subgroup our population:
This included any person answering yes to :
Any history of sexually transmitted diseases in the past 5 years
and/or ever having one or more of the following risk factors:
History of hemophilia and had received blood clotting factors before
Being a man who has had sex with men,
Used intravenous street drugs,
Traded sex for money or drugs,
Tested positive for Human Immunodeficiency Virus (HIV) or
Had sexual contact with anyone with any of the above risk factors
I would like to stress that the second question is a multi-component question in which we do know which risk factor the person is answering to. They only yes or no if they fall into any of the above risk groups.
Additionally, for the final data analysis, we only focused on adults within the age group of years old.

9. Methods (cont.) Weighted analysis with SUDAAN
Bivariate analysis using chi-square test
Assess significant characteristics associated with receipt of at least one dose of hepatitis B vaccine by high-risk adults years old
With the NHIS dataset, we did a weighted analysis with SUDAAN.
Bivariate analysis was done where chi-square was used to determine significance with a p value <.05
By doing this, we could assess the significant characteristics associated with receipt of at least one dose of hepatitis B vaccine among these high-risk adults between years old

10. Results
Of 32,374 respondents, 1091 adults (3%) between years old reported high-risk characteristics
RESULTS
Of the 32,374 respondents to the NHIS, 3% or 1091 adults were included in our analysis for high-risk factors based on their response to the survey

11. Results (cont.)
Only 32.6% of high-risk adults identified by this survey reported ever having received at least one dose of hepatitis B vaccination (n=365)
Only 23.0% reported receiving the three-dose series (n=249)
Of these individuals, only 32.6% reported ever receiving at least one dose of hepatitis B vaccine.
And only 23% reported receiving the complete three dose series

12. Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o
Age group n
Weighted % vaccinated
95% CI
18-29 years
409
39.4
(33.8, 45.0)
30-39 years
395
30.6
(25.0, 36.1)
40-49 years
287
25.2
(19.8, 30.7)
Now I will discuss the significant factors from the analysis:
Here you can see that of the high risk adults, younger adults such as those years old, had higher coverage levels. In this table, 39.4% of the years old group was vaccinated compared to 30.6% of the years old group and only 25% of the years old group.

13. Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o
Source of primary care n
Weighted % vaccinated
95% CI
Has primary care source
900
34.8
(31.2, 38.3)
Does not have primary care source
191
21.5
(14.7, 28.3)
Having an established source of primary care was also significant where of the high risk adults who had an identified source, almost 35% had received at least one hepatitis B vaccine while of those without a source of care only 21% had been vaccinated at least once

14. Number of visits in the past year
Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults y/o
Number of visits in the past year n
Weighted % vaccinated
95% CI
More than one visit
721
36.1
(32.3, 39.9)
Only one visit
169
26.5
(19.0, 34.1)
None
201
24.7
(17.2, 32.1)
And if one had gone to a clinic for care more than one time in a year, 36% had been vaccinated compared to only 27% who only went once in that year or 25% who did not go at all during the year.
I would like to note from this slide that even with adults who had more than one visit, only 36% had ever received a hepatitis vaccine which reflects an abundance of missed opportunities in the clinic.

15. Ever had pneumococcal vaccine
Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults y/o
Ever had pneumococcal vaccine n
Weighted %
vaccinated
95% CI
Yes
108
52.0
(39.8, 64.1) No
956
30.7
(27.4, 34.1)
Having a pneumococcal vaccine was significantly associated where of the high-risk adults who had ever had a pneumococcal vaccine, 52% had also had a hepatitis B vaccine, while of those who has not received a pneumoccal vaccine, only 30% had had a hepatitis B vaccine

16. Had current year influenza vaccine n
Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults y/o
Had current year influenza vaccine n
Weighted % vaccinated
95% CI
Yes
200
48.4
(39.3, 57.6) No
889
28.9
(25.5, 32.4)
Similarly with influenza, if one had had a current year vaccine, 48% also had been vaccinated for hepatitis B at least once, while if one did not have a current year flu shot, then only 29% had a hepatitis B vaccine, too

17. Had ever had HIV blood test
Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults y/o
Had ever had HIV blood test n
Weighted %
vaccinated
95% CI
Yes
787
36.5
(32.8, 40.3) No
295
23.7
(18.2, 29.2)
Other significant variables in the analysis included that if one was a high risk adult and had had an HIV test, 36% had also had a hepatitis B vaccine compared to 24% of those who had not had an HIV test

18. Characteristics associated with >1 doses hepatitis B vaccine among high-risk adults 18-49 y/o
Ever donated blood n
Weighted %
vaccinated
95% CI
Yes
326
37.2
(31.2, 43.3) No
765
30.6
(27.0, 34.1)
And blood donation was also significant in that of those who had donated blood before, 37% had had a hepatitis B vaccine while if one had not donated before, then only 30% had been vaccinated

19. Factors not associated with hepatitis B vaccination
Gender
Race/ethnicity
Educational level attained
Employment status
Income
Region living in the US
Insurance status (Covered/not covered)
Factors that were not associated with hepatitis B vaccination among these high risk adults included the following:
Gender
Race/ethnicity
Educational level attained
Employment status
Income level
Region living in the US
And Insurance status such as covered vs. not covered

20. Conclusion
Hepatitis B vaccination rates among high-risk adult groups are overall low
Greater efforts are needed to vaccinate this group
We need to avoid missed opportunities
In conclusion,
Hepatitis B vaccination rates are overall low among high risk adult groups
And greater efforts are needed to vaccinate this group
Most importantly, with these overall low coverage rates, we need to avoid any missed opportunities for vaccination when these people are in the clinic

21. Conclusions (cont.)
Factors associated with receipt of hepatitis B vaccine among high-risk adults include:
Having a source of primary care
Having more than one clinic visit in a year
Having a pneumococcal or current year influenza vaccine
Having ever had an HIV test
Having ever donated blood
From our analysis, certain factors have been determined to be significantly associated with receipt of a hepatitis B vaccination for this high risk group:
Having a source of primary care
Having more than one clinic visit in a year
Having had a pneumococcal or current year influenza vaccine
Having had an HIV test ever
or having donated blood ever.

22. Limitations Self-reported information regarding high risk factors
Self-reported vaccination status-
not provider verified
Occupation was not accounted for in assessing vaccination status
Health care utilization in the past year does not adequately reflect lifetime receipt of hepatitis B vaccine
However, there are Limitations in this analysis that need to be noted
Which include
The fact that the information is primarily self reported by the respondent regarding their high risk behavior and vaccination status with hepatitis B. There is no provider verification of the information
Occupation was not accounted for in assessing vaccination status, such as health care workers who are most likely to have higher rates of coverage due to their jobs,
And health care utilization in the past year does not adequately reflect hepatitis B coverage in that there is a possibility of receiving a hepatitis B vaccine at any time during your lifetime

23. Recommendations
Encourage using primary care services for immunizations
Regular use of health care (more than once a year) should be emphasized
Providers should not forget about older age groups who may be high-risk
Recommendations we would like to make from the analysis are the following:
Encourage using primary care services for immunizations
Encourage regular use of health care services, in that visits should occur more than once a year
Providers should be informed to not forget that their older age groups may also be at high risk for hepatitis B and still need vaccination to prevent acute and/or chronic disease

24. Recommendations (cont.)
Investigate the use of non-traditional settings for vaccination—ie. HIV testing centers, blood donation centers and STD clinics to increase coverage levels
Use evidence-based strategies to raise coverage levels—such as Client or Provider education within multi-component interventions
We should also investigate using nontraditional settings for vaccinating adults for hepatitis B such as HIV testing centers, STD clinics, and even blood donation centers
And lastly we should use evidence based strategies to help raise coverage levels, such as client and provider education within multi-component interventions
Thank you

25. Thank you!