Availability of Hepatitis B Vaccine for HighRisk Teens

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Availability of Hepatitis B Vaccine for High-Risk
Teens

• Stanley Schaffer, Peter G. Szilagyi, Sandra
  Ambrose, Richard Barth, Sharon Humiston, Laura
  Shone
• Dept. of Pediatrics, University of Rochester
• Hussain Yusuf, Donna Rickert, Abby Shefer
• National Immunization Program, CDC
• Funding was received from the Centers for Disease
  Control and Prevention through the Association of
  Teachers of Preventive Medicine

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Background

• Most individuals with hepatitis B contract it in
  adolescence or early adulthood
• Adolescents with high-risk behaviors (e.g.,
  promiscuity, drug abuse) are at particular risk
  for acquiring hepatitis B infection
• High-risk adolescents are more likely than others
  to seek medical care in alternative settings, be
  incarcerated or be in foster care
• Alternative health care settings do not always
  provide the full range of preventive health care
  services

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Research Questions

• How available is hepatitis B vaccine for
  high-risk adolescents who receive care in
  alternative health care settings?
• What are the barriers that hinder immunization?
• How can these barriers be overcome?

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Objectives of the Study

• To evaluate the availability of hepatitis B
  vaccine for adolescents who receive care at the
  following types of alternative health care
  settings
• School-Based Health Centers (SBHCs)
• Teen Clinics (TCs)
• STD Clinics (STDCs)
• Title X Family Planning Clinics (FPs)
• Planned Parenthood Facilities (PPs)
• Youth Correctional Facilities (YCFs)

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Objectives of the Study

• To determine the extent to which facilities that
  provide medical care to high-risk adults and
  teens (STD clinics, family planning clinics and
  Planned Parenthood facilities) also make
  hepatitis B vaccine available to their adult
  patient populations

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Objectives of the Study

• To evaluate state policies regarding the
  provision of hepatitis vaccines to
• incarcerated adolescents
• adolescents in foster care

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Objectives of the Study

• To assess vaccine financing and how financing
  influences provision of the vaccine
• To identify the barriers that may hinder the
  availability of hepatitis B vaccine to the
  adolescents and adults
• To propose ways to overcome these barriers

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Methods

• Methods included
• Identification of key questions through focus
  groups with national experts
• Development and implementation of national
  surveys of each of several types of alternative
  health care facilities and of state governments
• Post-survey focus groups to develop and refine
  recommendations

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Steps in the Study

• Gather and Update Denominator Data and Build a
  Database

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Denominator Data for Facility Surveys

• Multiple sources of denominator data (including
  directories of facilities gathered by CDC,
  professional groups, researchers and others)
• Total Sites Identified
• SBHCs 879
• TCs 300
• STDCs 2895
• FPs 3133
• PPs 128 affiliates
• YCFs 253 facilities where the average length
  of stay exceeds 120 days

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Steps in the Study

• Pre-survey focus groups with experts from each
  setting to gather background information and
  develop setting-specific survey items

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Pre-Survey Focus Groups

• 6 expert specific focus groups
• Focus groups deliberated several likely areas of
  concern
• Financing
• Confidentiality and Consent
• Availability of Records
• Education of Adolescents and Their Parents
• Staffing
• Focus of Care

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Steps in the Study

• Surveys of large national samples of SBHCs, TCs,
  STDCs, FPs, PPs and YCFs
• Surveys of each states youth authority medical
  director
• Surveys of each states social service department
  foster care program medical director

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Facility SurveySampling Strategy

• Total Sites
• SBHCs 400 of 879 randomly sampled
• TCs All 300 sampled
• STDCs 800 of 2895 randomly sampled
• FPs 600 of 3133 randomly sampled
• PPs All 128 affiliates sampled
• YCFs All 253 facilities sampled

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Facility Surveys

• Surveys tailored to specific facility types were
  designed, then sent out facility medical
  directors beginning in the summer of 2002
• Planned Parenthood surveys sent to affiliate
  medical directors instead of to individual
  clinics (PPFA urged directors to participate)
• 3 mailings and phone follow-up to non-responders
• 4th survey mailing (by fax) in January 2003

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State Level Surveys

• Surveys seeking information about state
  regulations/policies regarding teens in youth
  correctional facilities and in the foster care
  system
• Sent in spring 2003 to
• All 50 state youth authority medical directors
  youth authority medical directors in the District
  of Columbia and NYC
• All 50 state social service departments the
  social service department in the District of
  Columbia

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ResultsFacility Survey Response Rates ( of
Eligible Facilities Completing and Returning
Surveys)

• SBHCs 69
• TCs 65
• STDCs - 63
• FPs - 65
• PPs 68
• YCFs 77

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ResultsState Level Survey Response Rates

• State Youth Authority Medical Directors
• 62 response rate
• State Social Service Department Foster Care
  Medical Directors
• 46 response rate

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Facility Surveys of Respondents Who Thought
That It Is Important for Their Facility to
Provide Immunizations
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of Facilities Routinely Offering Hep B Vaccine
to Adolescents
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of Facilities Routinely Offering Hep B Vaccine
to Adolescents and Adults
Plt.01 Plt.05
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Financing of Hep B Vaccine for Teens Getting Care
at SBHCs and TCs
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Financing of Hep B Vaccine for Teens and Adults
Getting Care at STDCs, PPs and FPs
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Financing of Hep B Vaccine for Teens in YCFs
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Offering Hep B Vaccine to Adolescents by VFC
Participation
Awareness of and Participation in VFC
All comparisons were significant at P lt.05
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Barriers to Participation in VFC

• Maintenance of separate supplies for VFC-eligible
  and VFC-ineligible clients
• Burdensome reporting requirements
• Complicated application process
• Insufficient number of adolescent clients to
  justify participation (for STDCs, FPs, PPs)
• Insufficient information about VFC enrollment
  procedures

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Most Important Barriers Affecting Provision of
Hep B Vaccine to Teens Receiving Services at TCs
and SBHCs
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Most Important Barriers Affecting Provision of
Hep B Vaccine to Teens Receiving Services at
STDCs, FPs and PPs
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Most Important Barriers Affecting Provision of
Hepatitis B Vaccine to Incarcerated Youth
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Availability of Immunization Records for
Incarcerated Youth

• 85 of responding state youth authorities rely on
  school records for immunization information
• Regional immunization registries are not usually
  accessible to YCFs or do not include adolescent
  immunization information
• 58 of YCFs state that immunization records do
  not usually accompany incarcerated youths from
  placement to placement in the youth corrections
  system
• Several states are developing immunization
  registries for their youth correctional system

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Consent Issues for Adolescents in Foster Care

• Children in foster care often change medical
  providers
• States vary considerably in terms of who may
  provide consent to have the medical records of an
  adolescent in foster care transferred from
  physician to physician
• Many states require that the natural parents of
  adolescents in foster care provide consent for
  the transfer of medical and immunization records
  and the provision of immunizations

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Immunization Consent for Adolescents in Foster
Care
Consent from one or more of the following are
needed to provide hepatitis B vaccine to
adolescents in foster care
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Potential SolutionsSurvey Respondents Most
Commonly Suggested Strategies to Overcome Barriers

• Remind states that it is appropriate to consider
  the provision of hep B vaccine to be both a
  STD-and a cancer-prevention measure
• Develop and implement a coordinated public
  awareness campaign about hep B
• Simplify the VFC application and reporting
  processes
• Consider adding VFC-like funding for hep B
  vaccine for high-risk adults

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Steps in the Study

• After survey analysis, convene focus groups with
  experts from each setting to develop
  recommendations for CDC, ACIP and other
  stakeholders

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Study Teams Recommendations

• Streamline VFC application and reporting
  requirements
• Inform facilities and state governmental agencies
  dealing with adolescents about VFC ( savings)
• Strengthen immunization provision requirements
  for facilities receiving enhanced Medicaid
  funding (EPSDT) for adolescent preventive care
  services
• Consider additional supplemental funding to
  support vaccination at alternative health care
  facilities
• Develop a VFC-like program to provide vaccine to
  high-risk uninsured and underinsured adults
• Support the expansion of immunization registries
• Support the use of computerized on-line medical
  records for teens who are in YCFs

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Other Recommendations

• Urge CDC to work with accrediting groups,
  national organizations, other government agencies
  and interested stakeholders to jointly develop
  and disseminate recommendations to alternative
  health care facilities
• Support further testing of hep B vaccine to
  consider expanding use of the 2-shot series and
  shortened intervals between vaccinations
• Urge CDC to work with states and key stakeholders
  to develop model state regulations to facilitate
  coordinated consent procedures for vaccination of
  incarcerated youth and minors in foster care