# Presentation: 100418

## 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

## 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

## 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

## 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

## 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________

## 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________

## 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

## 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

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## 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

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## 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

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## 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

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## 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

## 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

## 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

## Overview of Women WhoReceived Vaccination

| Year | # Women Visited STD Clinic | # Received
1st Dose |
| --- | --- | --- |
| 2002 | 4591 | 880 (19%) |
| 2003 | 3156 | 730 (23%) |
| Totals | 7747 | 1610 (21%) |

## Overview of Women WhoReceived Vaccination

| Year | # Received
1st dose | Hispanic | Black | White | Other |
| --- | --- | --- | --- | --- | --- |
| 2002 | 880 | 291 (33%) | 215 (24%) | 329 (37%) | 44 (5%) |
| 2003 | 730 | 250 (34%) | 152 (21%) | 290 (40%) | 37 (5%)  |
| Totals | 1610 | 541 (34%) | 367 (23%) | 619
(38%) | 81
(5%) |

## Overview of Women WhoReceived Vaccination

| Year | # Received
1st dose | Years of Age |  |  |  |
| --- | --- | --- | --- | --- | --- |
|  |  | 15-19 | 20-29 | 30-39 | 40+ |
| 2002 | 880 | 52
(6%) | 513
(58%) | 203
(23%) | 112
(13%) |
| 2003 | 730 | 29
(4%) | 429
(59%) | 173
(24%) | 99
(14%) |
| Totals | 1610 | 81
(5%) | 942
(59%) | 376
(23%) | 221
(13%) |

## 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%) |

## Positive STD Results OnDay of First Dose

|  | GC | CT | HCV* | PID | Trich |
| --- | --- | --- | --- | --- | --- |
| 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%) |

## 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

## 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