1. Viral Hepatitis Prevention Services at Denver Public Health Julie Subiadur, RN BSN CCRC, Project Coordinator Laura Lloyd, MPH, Project Analyst Kees Rietmeijer, MD MSPH, Principle Investigator

2. DPH Site Characteristics Prior to December 2002 STD Clinic – a free walk in clinic open to the public regardless of residency in Denver; approximately 70-130 patients seen daily; 20,000 visits per year CTS Clinic – a free appointment-based clinic offering both confidential and anonymous HIV testing; approximately 3000 visits per year DCJ Screening clinic – DPH personnel offering HIV, HCV and STD screening services to consenting jail inmates since March 2000; approximately 60 inmates seen per month

3. Timeline of services 8/15/99 – HBV vaccine available to high risk STD clients 7/20/01 – HAV and HBV vaccine offered to all DCJ clients 1/15/02 – HBV vaccine offered to all STD and CTS clients 5/01/02 – HAV vaccine offered in STD and CTS to IDU, MSM, and HCV+ clients 7/01/02 – HAV vaccine offered in STD and CTS to working prostitutes

4. Referral Process Client seen per usual STD clinic visit Paper screening form clipped to chart to remind clinician to screen for eligibility Screening forms collected by clerical staff and entered into database Eligible, consenting clients escorted or directed to Denver Public Health Immunization Clinic with paper referral form (same floor, 50 feet away) Immunization Clinic doses client and enters information into Adios database

5. HBV Screening Form 8/15/99 – 1/14/01 Patient’s risk: MSM, IDU, sex partner of MSM or IDU,  2 sex partners in past 4 months, history of STD including today, known HCV+ (77% of clients fit eligibility criteria) Is patient interested in getting vaccine today? Or later? If no, why not? –Already had vaccine? –Already had disease? –No perceived need/not interested? –Other________

6. HAV / HBV Screening Form 1/15/01 – Present Is patient interested in getting HBV vaccine today? Or later? –If no, why not? Already had vaccine? Already had disease? No perceived need/not interested? Other________ Current IDU/MSM, HCV+, or working prostitute? Interested in HAV vaccine today? Or later? –If no, why not? Already had vaccine? Already had disease? No perceived need/not interested? Other________

7. Hepatitis B Vaccine in STD Clinic 8/15/99 – First offered to high-risk patients (MSM; IDU; partner of MSM or IDU; history of STD ever including today; >2 partners in past 4 months) 1/15/02 – Offered to all patients visiting clinic Patients screened by clinicians and forms filled out for data entry; recently, screening added to the charting process Patients referred to Immunization clinic for dosing; project staff also giving vaccines in STD clinic 2/2/04 decreased offer to those  23 years old unless foreign or out of state education, other risk

8. Calculation of Completion Rates First dose: # received dose 1 # eligible Second dose: # received dose 2 within 60 days of dose 1 # received dose 1 and had 60 days of follow-up Third dose: # received dose 3 within 1 year of dose 1 # received dose 2 and had 1 year of follow-up since first dose

12. Hepatitis B Vaccine in the DCJ Screening Clinic 7/20/01 – Offered to all inmates voluntarily requesting STD testing Inmates are tracked in the jail and called to infirmary for follow up doses if still incarcerated If released, inmates can come to STD or Immunization clinic for follow up doses 2/2/04 decreased offer to those  23 years old unless foreign or out of state education, other risk

14. Hepatitis B Vaccine in CTS Clinic 1/15/02 – Hepatitis B vaccine offered to all CTS patients CTS staff screening patients and filling out forms for data entry Patients referred to Immunization clinic or dosed in STD clinic when staff available 2/2/04 decreased offer to those  23 years old unless foreign or out of state education, other risk

17. Hepatitis A Vaccines in DPH Clinics 7/20/01 – Offered to all inmates at DCJ screening clinic; jail clients especially fearful of contracting HAV in jail food! 5/01/02 – Offered to all MSM, IDU, and HCV+ patients at STD and CTS clinics Vaccines are given in DCJ, STD, or Immunization clinics; inmates are tracked and re-dosed in jail or can come to other clinics if released

22. Tracking Issues We had access to already established vaccine database designed for tracking pediatric vaccinations within Denver Health system Many providers and sites have access; records available for any dosing within system Major negotiations required to add clinic, antigen tracking Major statistical issues to abstract particular data from this system

23. Use of Twinrix Twinrix is combination HAV/HBV vaccine given in 3 doses as on HBV schedule DPH was given 180 doses to use, first given in DCJ but moved to MSM in STD/CTS Issues around prior immunizations/disease/dose tracking must be considered before using Twinrix routinely

24. Program Initiation Issues Difficult to anticipate database complexities within STD, CTS and Adios Transitions with adding services not as smooth as hoped, especially in terms of data collection In retrospect, maybe would have developed additional services differently e.g. comparable databases for all sites prior to initiation, consistent screening techniques, on site dosing personnel sooner In future, will have clearer understanding of additional services impact on delivery and database systems for smoother implementation of expanded services

25. Overview of Women Who Received Vaccination Year # Women Visited STD Clinic # Received 1 st Dose 20024591880 (19%) 20033156730 (23%) Totals77471610 (21%)

26. Overview of Women Who Received Vaccination Year # Received 1 st dose HispanicBlackWhiteOther 2002880 291 (33%) 215 (24%) 329 (37%) 44 (5%) 2003730 250 (34%) 152 (21%) 290 (40%) 37 (5%) Totals1610 541 (34%) 367 (23%) 619 (38%) 81 (5%)

27. Overview of Women Who Received Vaccination Year # Received 1 st dose Years of Age 15-1920-2930-3940+ 2002880 52 (6%) 513 (58%) 203 (23%) 112 (13%) 2003730 29 (4%) 429 (59%) 173 (24%) 99 (14%) Totals1610 81 (5%) 942 (59%) 376 (23%) 221 (13%)

28. Admitted Risks of Women Who Received Vaccination Year Ever IDU Ever IDU Sex Partner Ever MSM Contact Ever Sex Worker 2002 47 (5.3%) 92 (10.4%) 48 (5.4%) 45 (5.1%) 2003 38 (5.2%) 56 (7.6%) 34 (4.6%) 23 (3.2%) Totals 85 (5.3%) 148 (9.2%) 82 (5.1%) 68 (4.2%)

29. Positive STD Results On Day of First Dose GCCTHCV*PIDTrich 2002 38 (4.7%) 89 (11.1%) 11 (16%) 35 (4%) 11 (1.8%) 2003 25 (3.7%) 67 (9.9%) 2 (2%) 26 (3.6%) 3 (0.5%) Totals 63 (4.3%) 156 (10.5%) 13 (13%) 61 (3.8%) 14 (1%)

30. Conclusions and Implications Persons at high risk for HIV and other STDs are also at high risk for viral hepatitis, making the discussion of viral hepatitis a natural fit in STD and CTS clinics. Hepatitis vaccines are fairly well accepted by STD patients especially if given within the same visit and same location. The next step in dealing with HCV+s is in creating accessible routes of referral for medical evaluation, which is certainly a huge challenge in the current economic climate

31. Acknowledgements Rebecca Rothbard, Joy Becker, Rita Sullivan and Cathy Cunningham – DPH Project Staff Gerrit Bakker, Mauricio Palacio, and Amy Warner – Colorado Department of Public Health and Environment (CDPHE) Mona Bedell, RN and the Denver Public Health Immunization Clinic Staff