Rachel McLean, MPH, Adult Viral Hepatitis Prevention Coordinator, STD Branch

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Reaching At-Risk Adults with Hepatitis A B
Vaccine
2009 California Immunization Summit Pasadena,
April 20, 2009

• Rachel McLean, MPH, Adult Viral Hepatitis
  Prevention Coordinator, STD Branch
• Steve Nickell, PhD, Research Coordinator,
  Immunization Branch
• California Department of Public Health

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Objectives

• Identify key settings for HAV/HBV vaccination for
  at-risk adults
• Learn 3 successes and challenges from Adult
  Hepatitis Vaccine Program
• Identify 3 strategies for increasing
  collaboration w/ community-based groups serving
  at-risk adults

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CDPH Viral Hepatitis Prevention Control
Activities

• Viral Hepatitis Strategic Plan
• Improving Surveillance Data Use
• Educating the Public Providers (testing vacc.
  guidelines, serology, referrals, care)
• Targeting Integrating Services (testing,
  vaccination, health ed. ? key settings)
• Driving Policy Change
• Viral Hepatitis Coordinating Committee

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CDPH Viral Hepatitis Prevention Control
Activities

• Adult Hepatitis Vaccine Project (AHVP)
  providing free Hepatitis A B vaccine to
  settings serving adults at-risk for viral
  hepatitis
• Syringe exchange, STD clinics, jails, drug
  treatment, HIV, primary care, etc.
• Perinatal Hepatitis (B) Prevention Program
• HCV testing at HIV testing sites
• Investigation of nosocomial infections
• Statewide viral hepatitis resource guide

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CDC Hepatitis B Adult Vaccine Recommendations
(2006)

• Persons at risk for infection by percutaneous or
  mucosal exposure to blood
• Current or recent injection drug users (IDUs)
• Household contact of HBsAg persons
• Residents and staff of institutions for
  developmentally disabled
• Health care and public safety workers with risk
  of exposure to blood or blood contaminated body
  fluids
• Persons with end stage renal disease, e.g.
  hemodialysis patients

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CDC Hepatitis B Adult Vaccine Recommendations
(2006), cont.

• Adults at risk of infection via sexual exposure
• Sex partners of HBsAg persons
• Sexually active persons who are not in a
  long-term , mutually monogamous relationship
  (i.e. more than 1 sexual partner in preceding 6
  months)
• Persons seeking evaluation or treatment for an
  STD
• MSM
• Others
• Travelers to HBV-endemic areas
• Persons with chronic liver disease
• Persons with HIV infection
• All persons seeking vaccine (specific risk factor
  not necessary)

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Acute Hepatitis B Rates by Age Group,
California, 2000 2007
2007 rates are provisional
Courtesy of Kathleen Winter, Immunization Branch
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CA Adult Hepatitis Vaccine Project

• 95 of new cases are now in adults
• Transmission
• U.S. Europe sexual parenteral
• Endemic regions perinatal, close contact
• Risk factors
• Behavioral
• Geographic origins (gt2 Hep. B prevalence)
• 2006 ACIP settings
• STD clinics
• HIV counseling and testing facilities
• Correctional facilities
• Substance abuse treatment program
• Syringe exchange/harm reduction programs
• Clinics serving MSM or IDU

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Geographic Distribution of Chronic HBV Infection
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CA Adult Hepatitis Vaccine Project

• 2007- CA IZ Branch commits federal Section 317
  funds to 1-year demonstration project
• CDPH IZ, STD, OA collaborate in release of RFA
• To distribute free HepB vaccine to settings
  serving at risk adults
• Hep. A Comb. Hep AB vaccines also offered (MSM,
  IDU, HBV, HCV, CLD)
• 2008 - CDC Adult Hepatitis Vaccination Initiative
  kicks in additional unspent 317 funds
• 2009 - Additional CDC funds Expanded to all
  counties, encouraged partnering with community
  organizations serving at-risk adults.

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CA Adult Hepatitis Vaccine Project

• Eligibility
• Facility serving high-risk adults
• Available staff to vaccinate
• Plan to integrate vaccination service
• Proper storage and handling of vaccine
• Ability to document delivery
• Budget to pay for supplies

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CA AHVP Participation
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CA Adult Hepatitis Vaccine Project Total Doses
Summary (as of 3/31/09)
partial reporting for Q1 09
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Hepatitis Vaccine Protection in Teens and
Adults, 2007-2008
anti-HBs Ab titer of 10mIU/ml or higher.
Factors that may lower response rates are age gt
40 yrs, male, smoking, obesity, and immune
deficiency.
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Vaccine Dose in Series, 2007-2008
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Demographics of Hepatitis B Vaccinees, 2007-2008
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AHVP Successes

• High vaccine uptake demonstrates unmet need for
  adult vaccination among high-risk populations in
  CA
• Highlights
• Several LHDs shared vaccine with community
  partners serving HR or offered off-site
  vaccination services
• Clinics with higher rates of 2nd and 3rd doses
  used reminder/recall
• Several jail sites entered patient doses into the
  immunization registry

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AHVP Challenges/Lessons Learned

• CDC emphasis on behavioral risk is probably not
  best model for CA - need to also target
  foreign-born immigrants, e.g. APIs, from
  Hepatitis B endemic countries
• Participants provided services using existing
  staff resources a more successful program may
  require additional funding
• Requirement for client-level data reporting
  proved burdensome and has been relaxed for 2009
• Need for more state support

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AHVP - Current Status

• 188 total sites administering hepatitis vaccine
  to at-risk adults
• 38 of 61 local health jurisdictions represented -
  92 of adult population
• Targeting clinics serving API or other
  foreign-born immigrants
• Over 100,000 doses of Hepatitis B-containing
  vaccine available in 2009
• New participants are welcome

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Discussion Questions

• Why would your program be a good place for
  delivering HAV/HBV vaccine to at-risk adults?
• What barriers would you face?
• What strategies would you use to overcome them?
• What resources would you need?

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Strategies for Increasing Collaboration w/ CBOs

• Contact leaders/ providers in target populations
  (API, syringe exchange, LGBT, HIV programs, drug
  treatment, homeless)
• Advertise services in targeted media (ethnic
  media, gay lesbian papers)
• Partner with universities/private providers
• Identify alternate sites for vaccine delivery
  (pharmacies, churches, YMCA, etc.)

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Resources

• Adult Hepatitis Vaccine Program
• www.cdph.ca.gov/programs/immunize/Pages/AHVP.aspx
  
• Asian Liver Center
• http//liver.stanford.edu
• California Hepatitis Alliance
• www.calhep.org
• Harm Reduction Coalition
• www.harmreduction.org
• San Francisco Hep B Free Campaign
• www.sfhepbfree.org

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Contact Information
Rachel McLean, MPH Adult Viral Hepatitis
Prevention Coordinator STD Control
Branch California Department of Public Health 300
Frank Ogawa Plaza, Suite 520 Oakland, CA
94612 Rachel.McLean_at_cdph.ca.gov 510-625-6022 ph
510-836-0239 fax www.cdph.ca.gov
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Contact Information
Steve Nickell, PhD Adult Hepatitis Vaccine P
Coordinator, Immunization Branch California
Department of Public Health 850 Marina Bay
Parkway Richmond, CA 94804-6403 Steve.Nickell_at_cdph
.ca.gov 510-620-3780 ph 510-620-3774
fx www.cdph.ca.gov, www.eziz.org