Hepatitis B Screening and Vaccine Referral Program in an STD Clinic Denver, Colorado

1. Hepatitis B Screening and Vaccine Referral Program in an STD ClinicDenver, Colorado Julie Subiadur RN Jennifer Landrigan MHS Franklin Judson MD Mona Bedell RN John Douglas MD

2. Facts About Denver Metro Health Clinic • A free, walk-in clinic open to the public regardless of residency in Denver • Open Monday through Friday, with evening clinics on Mondays and Wednesdays • Average of 12,500 visits per year • Daily clinic visits average 70 clients per day

3. 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/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

4. HBV Screening Form 8/99-1/14/01 • 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________

5. Screening Results 8/99-11/01

6. Screening Results 8/99-11/01

7. Percentages Already Received Vaccine By Age Group

8. Screening Results 8/99-11/01

9. 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

10. Dosing Results 8/99-11/01

11. Return Rates for Second Dose n % OR (95% CI) Total 1347 37% Male 931 39% 1.48 (1.15-1.90) Female 416 31% Reference White 609 42% Reference African-American 354 31% 0.59 (0.44-0.78) Hispanic 384 32% 0.75 (0.57-0.99) *data available on 1347 of 1488 of patients who received a first dose

12. Return Rates for Second Dose n % OR (95% CI) <25 424 27% Reference 25-34 451 36% 1.52 (1.14-2.04) 35+ 472 45% 2.26 (1.69-3.01) Client-based 541 44% 1.97 (1.52-2.56) None 510 30% Reference Post-card 296 33% 1.16 (0.85-1.59) *data available on 1347 of 1488 of patients who received a first dose

13. Conclusions • The proportion of clients claiming prior history of Hep B or who have previously been vaccinated has significantly increased over the study period, among all age groups • About 30% of eligible clients received first dose of Hep B vaccine • Return rates were higher for male, white, and older clients; these variables remained significant in the multivariate model • Return rates for second doses were higher with a client-based reminder system, than with a postcard based system or none at all

14. Implications • It is questionable as to whether post-card reminders increase return rates; client-based reminder system are preferable • Extra efforts necessary to encourage clients to complete vaccine series • Even with free HBV vaccine, only 60% of eligible clients screened express interest • about 30% actually receive 1st vaccine • about 38% of those receiving 1st dose get 2nd dose, (11% of total eligible) • about 27% of those receiving 2nd dose get 3rd dose (3% of total eligible)

15. Other Approaches To Enhance Program Success • Enhanced literature encouraging vaccination (may increase acceptance) • On-site immunization versus referral to Immunization Clinic (to reduce initial no-shows) • Enhanced reminders (to reduce loss to follow up)