Karen A. Hennessey

Hepatitis B Vaccination Coverage among U.S. Adolescents, National Immunization Survey–Teen, 2006

PURPOSE To determine national estimates of hepatitis B vaccination among adolescents in the United States and factors associated with vaccination using provider-reported immunization histories. METHODS Data were analyzed from the 2006 National Immunization Survey-Teen, a random-digit-dialed telephone survey sampling households with adolescents aged 13-17 years. Provider-reported immunization histories were obtained to determine hepatitis B vaccination coverage. RESULTS The household response rate was 56.2% (n = 5468); provider data was obtained from 52.7% (n = 2882). Overall up-to-date hepatitis B vaccination coverage was 81.3%; older adolescents aged 15-17 years old had lower coverage than younger adolescents aged 13-14 years old, (77.6% vs. 87.1%, p < .05). More than half of the 13-14-year-olds had received vaccination before age 3 years, while 15-17-year-olds received vaccination throughout childhood. Factors associated with vaccination coverage among adolescents 13-14 years old included private health insurance coverage and having a parent-reported health care visit at age of 11-12 years. Factors associated with vaccination coverage among adolescents 15-17 years old included living in the Northeast, having a mother who was married, and having a parent-reported health care visit at 11-12 years. CONCLUSIONS In 2006, adolescents 15-17 years old had lower hepatitis B vaccination coverage compared to those 13-14 years old. Younger adolescents likely benefited from universal recommendations in 1991 and received hepatitis B vaccination during early childhood. A healthcare visit at age 11-12 years has been recommended by professional organizations and was associated with hepatitis B vaccination in our survey. Parents and providers should routinely review adolescent immunizations.

Widespread Paralytic Poliomyelitis in Pakistan: A Case-Control Study to Determine Risk Factors and Implications for Poliomyelitis Eradication

Despite substantial efforts to eradicate poliomyelitis by administering oral poliovirus vaccine through routine immunization and annual national immunization days (NIDs), Pakistan reported 22% (1147) of the worldwide cases in 1997. Reasons for continued high poliomyelitis incidence include failure to vaccinate, vaccine failure, or inadequate immunization strategies. A case-control study was conducted to measure vaccination status and reasons for undervaccination among 66 poliomyelitis cases and 130 age- and neighborhood-matched controls. Cases were undervaccinated through routine immunization (matched odds ratio [MOR], 0.3; 95% confidence interval [CI], 0.1-0.5); however, NID immunization was similar for cases and controls (MOR, 0.6; 95% CI, 0.3-1.2). Reasons for undervaccination included not being informed, considering vaccination unimportant, and long distances to vaccination sites. Failure to vaccinate through routine immunization was a major risk factor for poliomyelitis in Pakistan. Successful NIDs alone will not interrupt poliovirus circulation in Pakistan, and children remain at risk unless routine immunization is strengthened or additional supplementary immunization is provided.

Hepatitis A vaccination coverage among adults aged 18-49 years in the United States.

BACKGROUND Hepatitis A is the most common type of hepatitis reported in the United States. Prior to hepatitis A vaccine introduction in 1996, hepatitis A incidence followed a cyclic pattern with peak incidence occurring every 10-15 years. During 1980-1995, between 22,000 and 36,000 hepatitis A cases were reported annually. Since 1996, hepatitis A vaccination recommendations have included adults at risk for infection and children living in communities with the highest disease rates. This study provides the first national estimates of self-reported hepatitis A vaccination coverage among persons aged 18-49 years in the United States. METHODS We analyzed the 2007 National Immunization Survey-Adult (NIS-Adult) data with restrictions to individuals aged 18-49 years. National estimates of hepatitis A vaccination coverage were calculated based on self-report and multivariable logistic regression analysis was used to identify factors independently associated with hepatitis A vaccination status. RESULTS Among adults aged 18-49 years, 12.1% (95% confidence interval, CI=9.9-14.8%) had received two or more doses of hepatitis A vaccine in 2007. Hepatitis A vaccination coverage was significantly higher among adults aged 18-29 years (15.6%) and adults aged 30-39 years (12.9%) compared with adults aged 40-49 years (8.3%). Coverage was significantly lower for Hispanics (7.1%) compared with non-Hispanic whites (12.5%). Characteristics independently associated with a higher likelihood of hepatitis A vaccination among persons aged 18-49 years included younger age groups, persons at or above poverty level, persons with public medical insurance, and persons who received influenza vaccination in the past season. CONCLUSIONS In 2007, self-reported hepatitis A vaccination coverage among adults aged 18-49 years was 12.1%. These data provide the first national hepatitis A vaccination coverage estimates among adults and are very important in planning and implementing strategies for increasing hepatitis A vaccination coverage among adults at risk for hepatitis A.

Improving hepatitis B vaccine timely birth dose coverage: Lessons from five demonstration projects in China, 2005–2009

BACKGROUND Delivery of a timely (within 24h) hepatitis B vaccine birth dose (TBD) is essential to prevent the long-term complications of hepatitis B virus (HBV) infection. China made substantial progress in hepatitis B immunization coverage, however, in 2004, TBD coverage was lower in Western, poorer provinces. METHODS We reviewed five demonstration projects for the promotion of TBD in rural counties in Qinghai, Gansu and Ningxia. Interventions consisted of (1) work to increase TBD coverage in hospitals, including training of health-care workers, (2) information, education and communication [IEC] with the population and (3) micro-plans to deliver TBD for home births. We evaluated outcome through measuring TBD coverage for home and hospital births. RESULTS These projects were implemented in the context of national efforts to promote institutional deliveries that lead to increases ranging from 10% to 17% to reach 43-97% proportion of institutional births at the end of the projects. Among institutional births, TBD coverage increased by 2% to 13% to reach post implementation coverage ranging from 98% to 100%. Among home births, TBD coverage increased by 7% to 56% to reach post implementation coverage ranging from 29% to 88%. Overall, TBD coverage increased by 4% to 36% to reach post implementation coverage ranging from 82% to 88%. CONCLUSIONS Demonstration projects based on combined interventions increased TBD coverage. Increases in institutional births amplified the results obtained. Use of standardized indicators for such projects would facilitate evaluation and identify intervention components that are most effective.

Implementing a national policy for hepatitis B birth dose vaccination in Philippines: Lessons for improved delivery

BACKGROUND An estimated seven million Filipinos (10-12% of the population) are chronically infected with hepatitis B virus (HBV). Achieving high birth dose coverage with hepatitis B vaccine is critical for achieving the World Health Organizations Western Pacific Regional goal of reducing the prevalence of chronic HBV among children 5 years of age to <2% by 2012. METHODS Seven months after the Philippines adopted a hepatitis B vaccine birth dose policy, hospitals with the highest number of deliveries were invited to participate in an assessment of implementation of the birth dose policy. Additionally, in metro Manila birth dose coverage was estimated before and after conducting a training workshop and supervisory follow-up for practitioners conducting home deliveries or deliveries at lying-in clinics. RESULTS Of the countrys largest 150 hospitals in terms of authorized bed capacity, 85 (56%) were included in this assessment. These hospitals had 55,719 deliveries during July-September 2007. Of these, 54% infants had a documented birth dose; however, only 22% were vaccinated within 24h of delivery. Having a copy of the hepatitis B vaccine vaccination policy (prevalence odds ratio [pOR]=4.7, 95% confidence interval [CI]=1.2-18.0), having standing orders pOR=4.8, 95% CI=1.3-18.1 and providing training pOR=18.9, 95% CI=5.3-67.0 were associated with >50% birth dose coverage in a hospital. In metro-Manila, regardless of place of birth, the training workshop and supervisory follow-up significantly improved hepatitis B vaccine administration within 24h after birth, increasing from 19% before to 74% after the training workshop and follow-up. CONCLUSIONS Experience in the Philippines showed that actions by national, regional and health facility policy makers such as establishing national policies, distributing detailed and specific guidelines, conducting effective training and supervision, and having hospital standing orders substantially increased hepatitis B vaccine birth dose coverage.

Hepatitis A Seroprevalence and Risk Factors Among Homeless Adults in San Francisco: Should Homelessness Be Included in the Risk-Based Strategy for Vaccination?

Objectives. Homeless adults have an increased risk of infectious diseases due to sexual and drug-related behaviors and substandard living conditions. We investigated the prevalence and risk factors for presence of hepatitis A virus (HAV) antibodies among homeless and marginally housed adults. Methods. We analyzed serologic and questionnaire data from a study of marginally housed and homeless adults in San Francisco from April 1999 to March 2000. We tested seroprevalance for total antibodies to HAV (anti-HAV) and analyzed data using Chi-square tests and logistic regression. Results. Of the 1,138 adults in the study, 52% were anti-HAV positive. The anti-HAV prevalence in this study population was 58% higher than the expected prevalence based on age-specific prevalence rates from the general population. Number of years of homelessness (≤1, 2-4, and ≥5 years) was associated with anti-HAV prevalence (46%, 50%, and 61%, respectively, p<0.001). We found other differences in anti-HAV prevalence (p<0.05) for ever having injected drugs (63% vs. 42% for non-injectors), being foreign-born (75% vs. 51% among U.S.-born), race/ethnicity (72%, 53%, and 45% for Hispanic, white, and black people, respectively), and increasing age (38%, 49%, and 62% among those aged <35, 35-45, and >45 years, respectively). These variables all remained significant in a multivariate model. Conclusions. We found overall anti-HAV prevalence elevated in this San Francisco homeless population compared with the general U.S. population. These data show that anti-HAV was associated with homelessness independent of other known risk factors, such as being foreign-born, race/ethnicity, and injection drug use. This increase indicates an excess risk of HAV infection and the potential need to offer hepatitis A vaccination as part of homeless services.

AIDS onset at high CD4+ cell levels is associated with high HIV load

To identify factors associated with development of AIDS at high CD4+ cell levels a nested case-control study using data from the Multicenter AIDS Cohort Study (MACS) was conducted. HIV-1-infected men who developed AIDS with > or =300/mm3 CD4+ cells (AIDS men) were compared to men who had > or =300/mm3 of CD4+ cells, but remained AIDS free for at least 2 years. The AIDS men had higher plasma HIV-1 RNA levels (mean 10(5.02) vs. 10(4.42), p<0.01) and neopterin levels (mean 18.3 vs. 11.5 units/ml, p<0.05) before the AIDS diagnosis than did the AIDS-free men. A significantly higher proportion of the AIDS men reported genital herpes within the year prior to their initial AIDS diagnosis than did the AIDS-free men (21.9 vs. 4.4%, p<0.05). The higher viral load at relatively high CD4+ cell levels in men who subsequently developed AIDS within 6 months supports the hypothesis that elevated levels of HIV precede CD4+ decline and are the major factor in determining risk of AIDS even at high levels of CD4+ cell levels.

The association between use of non-injection drug implements and hepatitis C virus antibody status in homeless and marginally housed persons in San Francisco

BACKGROUND Up to 17,000 persons in the USA became infected with hepatitis C virus (HCV) in 2007, and many cases have unknown transmission routes. To date research on transmission of HCV via shared implements used to snort or smoke non-injection drugs has been inconclusive. METHODS We tested stored sera for HCV antibodies (anti-HCV) in a large population-based study of homeless and marginally housed persons in San Francisco. We examined the association between sharing implements used for snorting and smoking drugs and anti-HCV while controlling for sociodemographic variables in those who denied ever injecting drugs (n = 430). We also examined the association of anti-HCV status with history of incarceration, tattoo and piercing history, sexual history and alcohol consumption. RESULTS Seventeen percent of our sample was anti-HCV positive. We found no statistically significant associations with sharing implements used to smoke or snort drugs with anti-HCV status in our various multivariate models. There was a statistically significant negative association between ever snorting cocaine and anti-HCV status (adjusted odds ratio: 0.39; 95% confidence interval: 0.21-0.73). There were no other statistically significant associations with any other measured covariates in multivariate analyses. CONCLUSIONS Our findings suggest that sharing implements to snort or smoke drugs is not a significant risk factor for anti-HCV-positive status.

Prevention of Viral Hepatitis

Persons incarcerated in correctional systems comprise approximately 0.7% of the U.S. population and have a disproportionately greater burden of infectious diseases, including infections with hepatitis viruses (National Commission on Correctional Health Care, 2002). Approximately 2% of prison and jail releasees have current or chronic hepatitis B infection compared to 0.4–0.5% in the general population; and at least 17% were infected with hepatitis C compared to 1.8% of the general population (Box 9.1) (McQuillan et al., 1999; Alter et al., 1999). On incarceration, all adults lose access to their usual public and private health-care and disease-prevention services. Their health care becomes the sole responsibility of either the correctional system (federal, tribal, state, or local) or, less frequently, the public health system (National Commission on Correctional Health Care, 1993). For the majority of persons, entry into the correctional system provides an opportunity to access health care that they could not access before. However, the rapid turnover of the incarcerated population, especially in jails, and the suboptimal funding of correctional health and prevention services, often limits the correctional system in providing both curative and preventive care. The significance of including incarcerated populations in community-based disease prevention and control strategies is now recognized by public health and correctional professionals (Glaser & Greifinger, 1993; Association of State and Territorial Health Officials, 2002). Improved access to medical care and prevention services for incarcerated populations can benefit communities by reducing disease transmission and associated medical costs (Conklin, Lincoln, & Flanigan, 1998; Mast, Williams, Alter, & Margolis, 1998; Silberstein, Coles, Greenberg, Singer, & Voigt, 2000; Kahn, Scholl, Shane, Lemoine, & Farley, 2002; Goldstein et al., 2002). Inmates who participate in health-related programs while incarcerated have lower recidivism rates and are more likely to maintain health-conscious behaviors (Conklin et al., 1998). Finally, because incarcerated persons have a high frequency of infection with hepatitis viruses, community efforts to prevent and control these infections require inclusion of the correctional population (CDC, 1998a, 2005; Fiore, Wasley, & Bell, 2006). Chapter 9