Hepatitis B Vaccination of Adolescents -- California, Louisiana, and Oregon, 1992-1994

Although hepatitis B vaccine has been available in the United States since 1982, acute and chronic hepatitis B virus (HBV) infection remains a public health problem (1). The comprehensive national strategy to prevent HBV transmission includes hepatitis B vaccination of adolescents, particularly in communities with high rates of injecting-drug use, teenage pregnancy, and/or sexually transmitted diseases (STDs) (2). However, vaccination of adolescents may be difficult because of their lack of routine health-care visits. This report describes hepatitis B vaccination programs for adolescents and preadolescents in schools and other settings in California, Louisiana, and Oregon during 1992-1994. California

During the 1992-93 school year, the San Francisco Department of Public Health and the San Francisco Unified School District began a voluntary, school-based hepatitis B vaccination program with free vaccine provided to students in two middle schools; two additional schools participated during the 1993-94 school year. None of the selected schools had preexisting health services or school nurses. Overall, 2115 seventh-grade students were eligible for vaccination since the beginning of the program. Most students were aged 11-13 years.

Educational and motivational approaches were used to encourage student participation. Science lessons focused on infectious diseases and the immune system. Specific information about hepatitis B and hepatitis B vaccination was presented in a schoolwide assembly, during which selected faculty members and the school principal were vaccinated. Students then took home a parent information packet that contained parental consent and refusal forms and educational material explaining the vaccination program and the need for protection from HBV infection. All materials were available in six languages. Incentives to return signed consent or refusal forms included extra credit points and a class party for students in classes in which all students returned a signed form within 5 days. Students received pencils, erasers, and folders after each vaccine dose and were eligible to attend a social event (e.g., a school dance or movie) after completion of the three-dose vaccine series. Based on a 0-, 1-, and 5-month vaccination schedule, vaccine doses were administered on 3 consecutive days during November, December, and April each year. For students absent during the regular vaccination clinics, makeup clinics were held 1- 2 weeks later.

During the 1992-93 school year, 577 (91%) students returned signed forms to accept or refuse vaccination; 418 (91%) of the students who had signed forms to accept vaccination completed the vaccine series (Table_1). Of the 39 students who had signed consent forms but did not complete the series, 33 (85%) left school during the vaccination program and were lost to follow-up, and six (15%) were chronically absent. During the 1993-94 school year, 1396 (94%) students returned signed forms to accept or refuse vaccination; 1065 (94%) of the students who had signed forms to accept vaccination completed the vaccine series (Table_1). Of the 262 parents who signed a form refusing vaccination, 152 (58%) reported that their child had already received hepatitis B vaccine or was currently receiving the vaccine series. No information is available for students whose parents declined vaccination.

Findings from a questionnaire survey of students regarding factors that influenced their decision to be vaccinated indicated

1. the desire to be protected from HBV infection was an important motivator; 2) positive peer pressure induced by the group incentive resulted in a greater proportion of students returning signed forms; and 3) individual incentives, such as pencils, folders, or eligibility to attend a social event, were not important. Louisiana

In 1992, a voluntary, school-based vaccination program, with free vaccine provided to students in the sixth, seventh, and eighth grades and special education classes, was initiated in a middle school in Baton Rouge, Louisiana. This school has an on-site health clinic with a full-time nurse. A total of 654 students aged 10-16 years were eligible for vaccination during the 1992-93 school year.

Presentations in each science class described the risks and consequences of HBV infection and the reasons for hepatitis B vaccination. Letters with consent forms sent by mail informed parents/guardians of the vaccination program and encouraged student participation; these letters included testimonials from patients with acute hepatitis B. Public service announcements about the program were broadcast on local radio stations, and a contest was held to design a T-shirt to publicize the program. Students completing the vaccine series received pens, coupons for soft drinks, and other incentives.

Vaccine was administered on 3 consecutive days in October, December, and March by nurses during special vaccination clinics. Students absent for vaccine administration were vaccinated later during regular clinic hours.

Overall vaccination coverage during the 1992-93 school year was 65% (Table_1). Vaccinated students did not differ substantially by sex, grade, or socioeconomic status as measured by enrollment status in Medicaid. Oregon

In early 1992, the Health Division, Oregon Department of Human Resources, began a free, statewide voluntary hepatitis B vaccination program in selected facilities that had preexisting health-care services and that served adolescents and young adults who were at increased risk for HBV infection. As of May 31, 1994, 4322 persons have been enrolled in the program and received at least one dose of vaccine in settings including juvenile detention centers, school-based primary-care clinics, residential facilities for psychosocially dysfunctional children, and family-planning and STD clinics. Almost all participants (99%) were aged less than 20 years; most (75%) were aged 15-19 years. No direct incentives were offered to either clients or site administrators for participation in the program.

In the clinics, enrollment rates are difficult to calculate because site administrators have considerable latitude in deciding who will be offered vaccine. In the juvenile detention centers and residential facilities, where vaccine usually is offered to everyone, consent rates were 87% and 88%, respectively. Clients who moved from one site to another (e.g., parolees from detention centers) were tracked by local health departments to ensure completion of the three-dose vaccine series.

Overall, 44 (2%) of 1916 clients screened for antibody against hepatitis B core antigen (anti-HBc) before vaccination had immunity resulting from past HBV infection (four were positive for hepatitis B surface antigen {HBsAg}). Based on these results, prevaccination screening has been discontinued. Of the 1520 anti-HBc-negative persons enrolled before May 31, 1993, a total of 1183 (78%) received three doses of hepatitis B vaccine (Table_1). Of the 337 participants lost to follow-up, 210 (63%) received two vaccine doses and may have partial immunity.

Reported by: L Boyer-Chu, MPH, T Bascom, J Fetro, PhD, School Health Dept, San Francisco Unified School District; L Unti, MPH, K Coyle, PhD, ETR Associates, Santa Cruz; A Gandelman, MPH, F Taylor, MD, Bur of Epidemiology and Disease Control, San Francisco Dept of Public Health. W Keene, PhD, J O'Banion, MPH, Health Div, Oregon Dept of Human Resources. W Cassidy, MD, Louisiana State Univ School of Medicine, Baton Rouge; R Tapia, Louisiana Dept of Health and Hospitals. Epidemiology and Surveillance Div, National Immunization Program; Div of Field Epidemiology, Epidemiology Program Office; Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The programs described in this report demonstrate that hepatitis B vaccination of adolescents can be implemented successfully in a variety of settings. Because more than 99% of children remain in school until age 13 years (3), school-based vaccination programs such as those in California and Louisiana can reach a large proportion of older children and young adolescents. Targeted hepatitis B vaccination programs such as that in Oregon suggest that adolescents, especially those at high risk for infection, also may be accessible in other settings.

The San Francisco program demonstrates that preexisting health services are not necessary to carry out vaccination; however, the presence of a clinic in the school may facilitate such programs. Parents, students, and school personnel may be more accustomed to the delivery of medical care at schools with clinics than at schools without clinics. In addition, school-based health personnel can provide follow-up for students who do not return consent forms or who miss vaccine doses. Implementing school-based vaccination programs in the absence of preexisting health services may require approaches not familiar to most public health personnel. The support of school officials should be enlisted early in the planning process, and vaccination program activities should be flexible and produce minimal disruption of school routines. Because most parents rarely visit the school or meet as a group, communication with them is usually written, with educational materials and consent forms sent home with students or by mail. Educating students about HBV infection and motivating them to seek vaccination will encourage them to participate in program activities and gain their assistance in informing parents or guardians and obtaining consent.

The overall strategy recommended by the Advisory Committee on Immunization Practices for eliminating HBV transmission in the United States includes multiple approaches (2). Prevention of perinatal HBV transmission and routine infant vaccination are most important because they can prevent infection at all ages. However, an estimated 91% of HBV infections in the United States are acquired during adolescence and adulthood (4), and much of the public health benefit of widespread infant vaccination will not be known until vaccinated infants become adolescents and adults. Catch-up vaccination of older children or adolescents could accelerate efforts to eliminate HBV transmission in the United States. Because adolescents have an average of less than one health-care visit per year (5), state and local health officials, education officials, and health-care providers should consider alternate settings (e.g., schools, juvenile detention facilities, residential facilities, and specialized clinics) when planning adolescent hepatitis B vaccination programs. When resources do not permit vaccination of multiple-age cohorts of adolescents, an alternative approach, illustrated by the San Francisco program, is continuous vaccination of students in a single grade or age cohort. Programs such as those described in this report also may provide models of health-care service-delivery systems capable of addressing other health needs of adolescents, including the delivery of other vaccines.

References

1. Alter MJ, Hadler SC, Margolis HS, et al. The changing epidemiology of hepatitis B in the United States: need for alternative vaccination strategies. JAMA 1990;263:1218-22.

2. ACIP. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-13):1-19.

3. Kominski R, Adams A. School enrollment: social and economic characteristics of students, October 1991. Washington, DC: US Department of Commerce, Bureau of the Census, 1991:1. (Current population reports; series P20, no. 469).

4. Margolis HS, Alter MJ, Hadler SC. Hepatitis B: evolving epidemiology and implications for control. Seminars in Liver Disease 1991;11:84-92.

5. NCHS. Pattern of ambulatory care in pediatrics: the National Ambulatory Medical Care Survey, United States, January 1980- December 1981. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1983; DHHS publication no. (PHS)84-1736.

TABLE 1. Hepatitis B vaccination consent rate and vaccination coverage, by eligible or
enrolled persons -- San Francisco; Baton Rouge, Louisiana; and selected sites, Oregon,
1992-1994
=================================================================================================
                                              Students receiving vaccine
                              Consent    ---------------------------------------
                               given        Dose 1       Dose 2       Dose 3
Site/             Target    -----------  -----------  -----------  -------------
 School year   population *  No.   (%)    No.   (%)    No.   (%)    No.   (%)
--------------------------------------------------------------------------------
San Francisco
  1992-93           634      457   (72)   456   (72)   452   (71)   418   (66)
  1993-94          1481     1134   (77)  1119   (76)  1093   (74)  1065   (72)

Baton Rouge,
  Louisiana
  1992-93           654      519   (79)   519   (79)   497   (76)   425   (65)

Oregon
  1992-May 31,
    1993            ---      ---    ---  1520    ---    ---   ---  1183   (78) +
--------------------------------------------------------------------------------
* May include persons who had already received or were receiving hepatitis B vaccine elsewhere.
+ Percentage of persons who received first dose of vaccine and were negative for antibody to
  hepatitis B core antigen.
=================================================================================================

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