Availability of Hepatitis B Vaccine for High-Risk 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
              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
      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?
       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)
      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
      Objectives of the Study
   To evaluate state policies regarding the
    provision of hepatitis vaccines to:
      incarcerated adolescents
      adolescents in foster care
   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
                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
       Steps in the Study

1.   Gather and Update Denominator
     Data and Build a Database
      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
         Steps in the Study

2.   Pre-survey focus groups with experts
     from each setting to gather background
     information and develop setting-
     specific survey items
    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
         Steps in the Study
3.   Surveys of large national samples of SBHCs,
     TCs, STDCs, FPs, PPs and YCFs
4.   Surveys of each state’s youth authority
     medical director
5.   Surveys of each state’s social service
     department foster care program medical
     director
          Facility Survey
         Sampling 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
           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
         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
              Results:
  Facility Survey Response Rates
(% of Eligible Facilities Completing and
           Returning Surveys)
             SBHCs – 69%
             TCs – 65%
             STDCs - 63%
             FPs - 65%
             PPs – 68%
             YCFs – 77%
             Results:
State Level Survey Response Rates

  State Youth Authority Medical Directors
     62% response rate
  State Social Service Department Foster
   Care Medical Directors
     46% response rate
           Facility Surveys
 % of Respondents Who Thought
   That It Is Important for Their
 Facility to Provide Immunizations
School-Based Health Centers       99%
Teen Clinics                      99%
STD Clinics                       99%
Title X Family Planning Clinics   94%
Planned Parenthood Affiliates     87%
Youth Correctional Facilities     99%
% of Facilities Routinely Offering
 Hep B Vaccine to Adolescents
           All        High-Risk     Not Offered
        Adolescents   Adolescents       to
                                    Adolescents
SBHCs      89%           1%            10%
TCs        97%           2%            <1%
STDCs      76%           7%            16%
FPs        72%           5%            23%
PPs        35%           7%            58%
YCFs       92%           3%             5%
 % of Facilities Routinely Offering Hep B
   Vaccine to Adolescents and Adults
Facility and       Offered to    Offered to     Not
Patient Pop.          All       Highest Risk   Offered
                                   Only
STDCs-Teens          75%**           7%         16%
STDSs-Adults         38%**         26%          34%

FPs-Teens            71%**          5%          23%
FPs-Adults           35%**         22%          41%

PPs                  35%*           7%          58%
PPs                  27%*          12%          58%
**P<.01   *P<.05
Financing of Hep B Vaccine for Teens
   Getting Care at SBHCs and TCs
                           Hepatitis B Funding
     100%

      80%
                                                                               SBHC
      60%

      40%
                                                                               TC
      20%

      0%
                           State/Local
            VFC/Medicaid




                                                     Full/Part Out




                                                                     Private
                                         Insurance




                                                                     Sector
                                                      of Pocket
                                           Private
                              Govt
Financing of Hep B Vaccine for Teens and Adults
      Getting Care at STDCs, PPs and FPs
                              Hepatitis B Vaccine Funding for Adolescents
          60%                                                                                                                           STD Clinics
          50%
          40%
                                                                                                                                        PPFA
          30%
                                                                                                                                        Affiliates
          20%
          10%                                                                                                                           Family
           0%                                                                                                                           Planning




                                                        State/Local
                           VFC/Medicaid




                                                                                                     Full/Part Out




                                                                                                                           Private
                                                                                  Insurance




                                                                                                                           Sector
                                                                                                                                        Clinics




                                                                                                      of Pocket
                                                                                    Private
                                                           Govt
                             Hepatitis B Vaccine Funding for Adults
        60%                                                                                                                          STD Clinics
        50%
        40%
                                                                                                                                     PPFA Affiliates
        30%
        20%
                                                                                                                                     Family
        10%                                                                                                                          Planning
        0%                                                                                                                           Clinics
                                          State/Local
                Medicaid




                                                                                              Full/Part




                                                                                                                     Private
                                                                      Insurance




                                                                                                                     Sector
                                                                                              Pocket
                                                                                               Out of
                                                                        Private
                                             Govt
               Financing of Hep B Vaccine
                   for Teens in YCFs
% of sites receiving funding




                                                     Hepatitis B Vaccine Funding

                               60%   53.9%
                               50%
                               40%                      29.9%
                               30%
                               20%
                               10%                                     1.2%        1.8%             2.4%
                                0%
                                                         State/Local




                                                                                    Out of Pocket




                                                                                                    Private
                                                                       Insurance
                                      VFC/Medicaid




                                                                                                    Sector
                                                                         Private
                                                            Gov't
         Awareness of and Participation in VFC
  100%

   80%

   60%                                                                Aware
   40%
                                                                      Participate
   20%

    0%
           SBHC         TC         STDC         FP         PP   YCF


% Offering Hep B Vaccine to Adolescents by VFC
                 Participation
  100%

  80%
                                                                      Participating
  60%

  40%                                                                 Not
                                                                      Participating
  20%

   0%
           SBHC        TC         STDC         FP          PP   YCF
                  All comparisons were significant at P <.05
      Barriers to Participation in
                  VFC
1.   Maintenance of separate supplies for VFC-
     eligible and VFC-ineligible clients
2.   Burdensome reporting requirements
3.   Complicated application process
4.   Insufficient number of adolescent clients to
     justify participation (for STDCs, FPs, PPs)
5.   Insufficient information about VFC
     enrollment procedures
             Most Important Barriers Affecting
            Provision of Hep B Vaccine to Teens
           Receiving Services at TCs and SBHCs
          25                          Completion of Series


          20                          Lack of Insurance
                                      Info/Immunization Hx

          15                          Limited Understanding
Percent




                                      of Hep B
                                      Lack of Staff/Staff
          10                          Time
                                      Getting Parental
          5                           Consent
                                      Lack of Immunization
                                      Records
          0
               Teen Clinics   SBHCs
          Most Important Barriers Affecting Provision of
          Hep B Vaccine to Teens Receiving Services at
                      STDCs, FPs and PPs
    70                                      Completion of Series

    60
                                            Lack of Insurance
    50                                      Info/Immunization Hx


    40                                      Clients' Limited
Percent




                                            Understanding of Hep B

    30                                      Lack of Staff/Staff Time

    20
                                            Getting Parental
    10                                      Consent


          0                                 Lack of Funding
              STDCs      FPs       PPs
               Most Important Barriers Affecting
               Provision of Hepatitis B Vaccine to
                       Incarcerated Youth
                                     Funding
          50
          45                         Obtaining Parental Consent
          40
          35                         Completion of Series
          30
Percent




          25                         Short Term Stay in YCF
          20
          15                         Limited Understanding of Hep B
          10
                                     Lack of Staff/Staff Time
           5
           0
                                     Lack of Immunization Records
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
    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
           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
Percent of States
60
                              52
                                            Parent/Guardian
50             44
                                            Adolescent
40                                          Foster Parent
                                   32
                                            Casew orker
30
                                            Social Services Dept.

20                                          A Judge
                    12   12
                                        8
10

 0
          Potential Solutions:
  Survey 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
          Steps in the Study
6.   After survey analysis, convene focus groups
     with experts from each setting to develop
     recommendations for CDC, ACIP and
     other stakeholders
       Study Team’s 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
            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

				
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