National Update on Measles Cases and Outbreaks - United States, January 1-October 1, 2019.

During January 1-October 1, 2019, a total of 1,249 measles cases and 22 measles outbreaks were reported in the United States. This represents the most U.S. cases reported in a single year since 1992 (1), and the second highest number of reported outbreaks annually since measles was declared eliminated* in the United States in 2000 (2). Measles is an acute febrile rash illness with an attack rate of approximately 90% in susceptible household contacts (3). Domestic outbreaks can occur when travelers contract measles outside the United States and subsequently transmit infection to unvaccinated persons they expose in the United States. Among the 1,249 measles cases reported in 2019, 1,163 (93%) were associated with the 22 outbreaks, 1,107 (89%) were in patients who were unvaccinated or had an unknown vaccination status, and 119 (10%) measles patients were hospitalized. Closely related outbreaks in New York City (NYC) and New York State (NYS; excluding NYC), with ongoing transmission for nearly 1 year in large and close-knit Orthodox Jewish communities, accounted for 934 (75%) cases during 2019 and threatened the elimination status of measles in the United States. Robust responses in NYC and NYS were effective in controlling transmission before the 1-year mark; however, continued vigilance for additional cases within these communities is essential to determine whether elimination has been sustained. Collaboration between public health authorities and undervaccinated communities is important for preventing outbreaks and limiting transmission. The combination of maintenance of high national vaccination coverage with measles, mumps, and rubella vaccine (MMR) and rapid implementation of measles control measures remains the cornerstone for preventing widespread measles transmission (4).

Physician nonadherence with a hepatitis C screening program.

BACKGROUND: Testing for patients at risk for hepatitis C virus (HCV) infection is recommended, but it is unclear whether providers adhere to testing guidelines. We aimed to measure adherence to an HCV screening protocol during a multifaceted continuous intervention. SUBJECTS AND METHODS: Prospective cohort design to examine the associations between patient-level, physician-level, and visit-level characteristics and adherence to an HCV screening protocol. Study participants included all patients with a visit to 1 of the 3 study clinics and the physicians who cared for them. Adherence to the HCV screening protocol and patient-level, physician-level, and visit-level predictors of adherence were measured. RESULTS: A total of 8981 patients and 154 physicians were examined. Overall protocol adherence rate was 36.1%. In multivariate analysis, patient male sex (odds ratio [OR] = 1.18), new patient (OR = 1.23), morning visit (OR = 1.32), and patients' preferred language being non-English (OR = 0.87) were significantly associated with screening adherence. There was a wide variation in overall adherence among physicians (range, 0%-92.4%). Screening adherence continuously declined from 59.1% in week 1 of the study to 13.7% in week 15 (final week). When implementing complex clinical practice guidelines, planners should address physician attitudinal barriers as well as gaps in knowledge to maximize adherence.

Effect of influenza vaccination of healthcare personnel on morbidity and mortality among patients: systematic review and grading of evidence.

BACKGROUND: Influenza vaccination of healthcare personnel (HCP) is recommended in >40 countries. However, there is controversy surrounding the evidence that HCP vaccination reduces morbidity and mortality among patients. Key factors for developing evidence-based recommendations include quality of evidence, balance of benefits and harms, and values and preferences. METHODS: We conducted a systematic review of randomized trials, cohort studies, and case-control studies published through June 2012 to evaluate the effect of HCP influenza vaccination on mortality, hospitalization, and influenza cases in patients of healthcare facilities. We pooled trial results using meta-analysis and assessed evidence quality using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: We identified 4 cluster randomized trials and 4 observational studies conducted in long-term care or hospital settings. Pooled risk ratios across trials for all-cause mortality and influenza-like illness were 0.71 (95% confidence interval [CI], .59-.85) and 0.58 (95% CI, .46-.73), respectively; pooled estimates for all-cause hospitalization and laboratory-confirmed influenza were not statistically significant. The cohort and case-control studies indicated significant protective associations for influenza-like illness and laboratory-confirmed influenza. No studies reported harms to patients. Using GRADE, the quality of the evidence for the effect of HCP vaccination on mortality and influenza cases in patients was moderate and low, respectively. The evidence quality for the effect of HCP vaccination on patient hospitalization was low. The overall evidence quality was moderate. CONCLUSIONS: The quality of evidence is higher for mortality than for other outcomes. HCP influenza vaccination can enhance patient safety.

Effectiveness of a risk screener in identifying hepatitis C virus in a primary care setting.

OBJECTIVES: We evaluated an intervention designed to identify patients at risk for hepatitis C virus (HCV) through a risk screener used by primary care providers. METHODS: A clinical reminder sticker prompted physicians at 3 urban clinics to screen patients for 12 risk factors and order HCV testing if any risks were present. Risk factor data were collected from the sticker; demographic and testing data were extracted from electronic medical records. We used the t test, χ(2) test, and rank-sum test to compare patients who had and had not been screened and developed an analytic model to identify the incremental value of each element of the screener. RESULTS: Among screened patients, 27.8% (n = 902) were identified as having at least 1 risk factor. Of screened patients with risk factors, 55.4% (n = 500) were tested for HCV. Our analysis showed that 7 elements (injection drug use, intranasal drug use, elevated alanine aminotransferase, transfusions before 1992, ≥ 20 lifetime sex partners, maternal HCV, existing liver disease) accounted for all HCV infections identified. CONCLUSIONS: A brief risk screener with a paper-based clinical reminder was effective in increasing HCV testing in a primary care setting.

Primary care-based interventions are associated with increases in hepatitis C virus testing for patients at risk.

BACKGROUND: An estimated 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S. Effective treatment is available, but approximately 50% of patients are not aware that they are infected. Optimal testing strategies have not been described. METHODS: The Hepatitis C Assessment and Testing Project (HepCAT) was a serial cross-sectional evaluation of two community-based interventions designed to increase HCV testing in urban primary care clinics in comparison with a baseline period. The first intervention (risk-based screener) prompted physicians to order HCV tests based on the presence of HCV-related risks. The second intervention (birth cohort) prompted physicians to order HCV tests on all patients born within a high-prevalence birth cohort (1945-1964). The study was conducted at three primary care clinics in the Bronx, New York. RESULTS: Both interventions were associated with an increased proportion of patients tested for HCV from 6.0% at baseline to 13.1% during the risk-based screener period (P<0.001) and 9.9% during the birth cohort period (P<0.001). CONCLUSIONS: Two simple clinical reminder interventions were associated with significantly increased HCV testing rates. Our findings suggest that HCV screening programs, using either a risk-based or birth cohort strategy, should be adopted in primary care settings so that HCV-infected patients may benefit from antiviral treatment.

The cost-effectiveness of birth-cohort screening for hepatitis C antibody in U.S. primary care settings.

BACKGROUND: In the United States, hepatitis C virus (HCV) infection is most prevalent among adults born from 1945 through 1965, and approximately 50% to 75% of infected adults are unaware of their infection. OBJECTIVE: To estimate the cost-effectiveness of birth-cohort screening. DESIGN: Cost-effectiveness simulation. DATA SOURCES: National Health and Nutrition Examination Survey, U.S. Census, Medicare reimbursement schedule, and published sources. TARGET POPULATION: Adults born from 1945 through 1965 with 1 or more visits to a primary care provider annually. TIME HORIZON: Lifetime. PERSPECTIVE: Societal, health care. INTERVENTION: One-time antibody test of 1945-1965 birth cohort. OUTCOME MEASURES: Numbers of cases that were identified and treated and that achieved a sustained viral response; liver disease and death from HCV; medical and productivity costs; quality-adjusted life-years (QALYs); incremental cost-effectiveness ratio (ICER). RESULTS OF BASE-CASE ANALYSIS: Compared with the status quo, birth-cohort screening identified 808,580 additional cases of chronic HCV infection at a screening cost of $2874 per case identified. Assuming that birth-cohort screening was followed by pegylated interferon and ribavirin (PEG-IFN+R) for treated patients, screening increased QALYs by 348,800 and costs by $5.5 billion, for an ICER of $15,700 per QALY gained. Assuming that birth-cohort screening was followed by direct-acting antiviral plus PEG-IFN+R treatment for treated patients, screening increased QALYs by 532,200 and costs by $19.0 billion, for an ICER of $35,700 per QALY saved. RESULTS OF SENSITIVITY ANALYSIS: The ICER of birth-cohort screening was most sensitive to sustained viral response of antiviral therapy, the cost of therapy, the discount rate, and the QALY losses assigned to disease states. LIMITATION: Empirical data on screening and direct-acting antiviral treatment in real-world clinical settings are scarce. CONCLUSION: Birth-cohort screening for HCV in primary care settings was cost-effective. PRIMARY FUNDING SOURCE: Division of Viral Hepatitis, Centers for Disease Control and Prevention.

Performance of premarket rapid hepatitis C virus antibody assays in 4 national human immunodeficiency virus behavioral surveillance system sites.

SUMMARY: Performance characteristics of rapid assays for hepatitis C virus antibody were evaluated in 4 National HIV Behavioral Surveillance System injection drug use sites. The highest assay-specific sensitivities achieved for the Chembio, MedMira and OraSure tests were 94.0%, 78.9%, and 97.4%, respectively; the highest specificities were 97.7%, 83.3%, and 100%, respectively. BACKGROUND: The Centers for Disease Control and Prevention (CDC) estimates that 4.1 million Americans have been infected with hepatitis C virus (HCV) and 75%-80% of them are living with chronic HCV infection, many unaware of their infection. Persons who inject drugs (PWID) account for 57.5% of all persons with HCV antibody (anti-HCV) in the United States. Currently no point-of-care tests for HCV infection are approved for use in the United States. METHODS: Surveys and testing for human immunodeficiency virus (HIV) and anti-HCV were conducted among persons who reported injection drug use in the past 12 months as part of the National HIV Behavioral Surveillance System in 2009. The sensitivity and specificity of point-of-care tests (finger-stick and 2 oral fluid rapid assays) from 3 manufacturers (Chembio, MedMira, and OraSure) were evaluated in field settings in 4 US cities. RESULTS: Sensitivity (78.9%-97.4%) and specificity (80.0%-100.0%) were variable across assays and sites. The highest assay-specific sensitivities achieved for the Chembio, MedMira, and OraSure tests were 94.0%, 78.9% and 97.4%, respectively; the highest specificities were 97.7%, 83.3%, and 100%, respectively. In multivariate analysis, false-negative anti-HCV results were associated with HIV positivity for the Chembio oral assay (adjusted odds ratio, 8.4-9.1; P < .01) in 1 site (New York City). CONCLUSIONS: Sensitive rapid anti-HCV assays are appropriate and feasible for high-prevalence, high-risk populations such as PWID, who can be reached through social service settings such as syringe exchange programs and methadone maintenance treatment programs.

Evaluation of three rapid screening assays for detection of antibodies to hepatitis C virus.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) estimates that 3.2 million Americans are living with chronic hepatitis C virus (HCV) infection and 50%-70% are unaware of their status. Although therapies are available that can suppress or eliminate infection, identifying persons infected with HCV is challenging. Rapid tests could help identify many of these persons more expeditiously. METHODS: Three manufacturers, Chembio, OraSure, and MedMira, submitted HCV antibody (anti-HCV) rapid screening assays to the CDC for evaluation and comparison with established anti-HCV screening assays. The panel consisted of 1100 specimens drawn during 1997-1999 from persons reporting injection drug use. Sensitivity and specificity were assessed using 2 reference approaches, one based on the reactivity of samples in an anti-HCV screening assay and the other based on CDC HCV testing algorithm. RESULTS: The sensitivities of the Chembio, MedMira, and OraSure assays across the 2 approaches were 96.2%-98.0%, 86.8%-88.3%, and 97.8%-99.3%, respectively. The 3 assays had specificity of 99.5% or higher with no differences between assays. False rapid assay results were associated with human immunodeficiency virus positivity for both approaches for Chembio and MedMira. CONCLUSIONS: Rapid anti-HCV tests can provide sensitive and specific anti-HCV results for high-risk patients.

Models of community-based hepatitis B surface antigen screening programs in the U.S. and their estimated outcomes and costs.

OBJECTIVES: Information on the process and method of service delivery is sparse for hepatitis B surface antigen (HBsAg) testing, and no systematic study has evaluated the relative effectiveness or cost-effectiveness of different HBsAg screening models. To address this need, we compared five specific community-based screening programs. METHODS: We funded five HBsAg screening programs to collect information on their design, costs, and outcomes of participants during a six-month observation period. We categorized programs into four types of models. For each model, we calculated the number screened, the number screened as per Centers for Disease Control and Prevention (CDC) recommendations, and the cost per screening. RESULTS: The models varied by cost per person screened and total number of people screened, but they did not differ meaningfully in the proportion of people screened following CDC recommendations, the proportion of those screened who tested positive, or the proportion of those who newly tested positive. CONCLUSIONS: Integrating screening into outpatient service settings is the most cost-effective method but may not reach all people needing to be screened. Future research should examine cost-effective methods that expand the reach of screening into communities in outpatient settings.

HCV screening practices and prevalence in an MCO, 2000-2007.

BACKGROUND/OBJECTIVE: The Centers for Disease Control and Prevention recommends routine screening for the hepatitis C virus antibody (anti- HCV) among persons most likely to be infected. Little is known about anti-HCV screening and prevalence in routine practice settings. We studied anti-HCV screening rates, anti-HCV positivity, and demographic and risk factors associated with increased likelihood of anti-HCV screening or positivity in a managed care organization (MCO). METHODS: This was a retrospective observational study of 17-to-74-year-old MCO enrollees from 2000 to 2007 (N = 557,056; 1,949,499 enrollee years). The primary outcome measures were likelihood of anti-HCV screening and HCV positivity (both in the total population and among those screened). Independent variables were: birth cohort, gender, HCV risk factors, and socioeconomic status (SES) and race of residents' neighborhoods. Likelihood of each outcome as a function of the independent variables was estimated using logistic regression. RESULTS: Over the 8-year period, 4.31% of the total population received anti-HCV screening; 0.22% had a positive HCV result. Among those screened, HCV positivity was 5.15%. HCV screening and positivity rates increased over time. Both likelihood of HCV screening and HCV positivity were highest (P <0.05) among persons born during 1945-1964, males, those with HCV risk factors, and residents of neighborhoods of lower SES or with higher percentages of African Americans. CONCLUSIONS: Although HCV screening and detection improved in this MCO over an 8-year period, anti-HCV screening was lower than expected. Many persons at risk for HCV remained unscreened. Strategies for improving anti-HCV screening in routine practice are recommended for patients at increased risk.

Influenza vaccination coverage among pregnant women--National 2009 H1N1 Flu Survey (NHFS).

We sought to describe vaccination with influenza A (H1N1) 2009 monovalent (2009 H1N1) and trivalent seasonal (seasonal) vaccines among pregnant women during the 2009 through 2010 influenza season. A national H1N1 flu survey was conducted April through June 2010. The 2009 H1N1 and seasonal vaccination coverage estimates were 45.7% and 32.1%, respectively, among pregnant women aged 18-49 years. Receipt of a health care provider's recommendation for vaccination, perceived effectiveness of influenza vaccinations, and perceived high chance of influenza infection were independently associated with higher 2009 H1N1 and seasonal vaccination coverage. Pregnancy during October 2009 through January 2010 was independently associated with higher 2009 H1N1 vaccination coverage. The 2009 H1N1 vaccination level among pregnant women was higher than the seasonal vaccination level during the 2009 through 2010 season; it was also higher than vaccination among nonpregnant women with and without high-risk conditions. Health care providers and public health messaging played important roles in influencing vaccination behavior.

Forecasting the morbidity and mortality associated with prevalent cases of pre-cirrhotic chronic hepatitis C in the United States.

BACKGROUND: Without diagnosis and antiviral therapy, many patients with chronic hepatitis C infections will develop end-stage liver disease and die from complications. AIMS: To evaluate the future impacts of preventive interventions and treatment advances, this paper forecasts a baseline estimate of the future morbidity and mortality of prevalent hepatitis C when left untreated. METHODS: We simulated the future disease progression and death for all Americans with prevalent hepatitis C in 2005. To validate the model, we used past seroprevalence to forecast contemporary outcomes. We used the validated model to forecast future cases of end-stage liver disease, transplants, and deaths from 2010 to 2060, and we estimated credible intervals using Monte Carlo simulation. RESULTS: When programmed with past data, our model predicted current levels of hepatitis C outcomes with accuracy between ±1% and 13%. Morbidity and mortality from hepatitis C will rise from 2010 to a peak between the years 2030 and 2035. We forecasted a peak of 38,600 incident cases of end-stage liver disease; 3200 referrals for transplant; and 36,100 deaths. CONCLUSIONS: Because current rates of screening and treatment are low, future morbidity and mortality from hepatitis C are likely to increase substantially without public health interventions to increase treatment.

Prevalence of hepatitis B surface antigen among refugees entering the United States between 2006 and 2008.

The Centers for Disease Control and Prevention recommends hepatitis B surface antigen (HBsAg) testing to identify chronic hepatitis B virus infection for foreign-born persons from countries or regions with HBsAg prevalence of >or=2%. However, limited data exist to indicate which countries meet this definition. To address this data gap, we estimated the HBsAg prevalence among refugees entering the United States between 2006 and 2008. We contacted state refugee health coordinators and asked them to report the number of refugees, country of origin, and HBsAg prevalence among refugees screened in their jurisdiction during the most recently available 12-month period prior to August 2008. We pooled data across jurisdictions and calculated the prevalence for any country with more than 30 refugees entering the United States, and where this level of data was not available by country, continents were considered. Of the 47 jurisdictions contacted, we received basic information from 31, with nine jurisdictions reporting HBsAg prevalence by country of origin applicable to 31,980 refugees (approximately 42% of refugees entering the United States during the observation period). We estimated an HBsAg prevalence of 2.8% (95% confidence interval 2.6%-3.0%) for refugees overall. Of the 37 countries with 30 or more refugees entering the United States, 25 had a prevalence of >or=2%. Prevalence was highest among refugees from Africa and Southeast Asia, and lowest among refugees from the Middle East and South/Central America. In the eight countries for which we had comparison data, six had lower HBsAg prevalence than in 1991.

Recommendations for identification and public health management of persons with chronic hepatitis B virus infection.

Early identification of persons with chronic HBV infection enables infected persons to receive necessary care to prevent or delay onset of liver disease, and enables the identification and vaccination of susceptible household contacts and sex partners, interrupting ongoing transmission. Testing has been recommended previously to enable primary prevention of HBV infection among close contacts for pregnant women, household contacts and sex partners of HBV-infected persons, persons born in countries with hepatitis B surface antigen (HBsAg) prevalence of more than 8%, persons who are the source of blood or body fluid exposures that might warrant postexposure prophylaxis (e.g., needlestick injury to a healthcare worker or sexual assault), and to enable appropriate treatment for infants born to HBsAg-positive mothers and persons infected with human immunodeficiency virus. Recently, with the increasing availability of efficacious hepatitis B treatment, the Centers for Disease Control and Prevention published new recommendations for public health evaluation and management for chronically infected persons and their contacts and extended testing recommendations to include persons born in geographic regions with HBsAg prevalence of greater than 2%, men who have sex with men, and injection drug users. Patient and provider education, developing partnerships between health departments and community organizations, and other resources will be needed to assure appropriate populations are tested and care provided for persons newly identified as HBsAg-positive.

Physician practices regarding adult hepatitis B vaccination: a national survey.

BACKGROUND: Less than 50% of adults with risk factors for hepatitis B infection have been vaccinated. Although primary care settings typically serve an important role in immunization delivery, little is known about adult hepatitis B vaccination practices in primary care, including the use of strategies such as standing orders to improve immunization rates. The objectives of this study were to assess, among family physicians and general internists, current approaches to assessing adult patients for hepatitis B risk factors, reported hepatitis B vaccination practices, and attitudes about standing orders for hepatitis B vaccination. METHODS: From September to November 2006, a national sample of 433 family physicians and 420 general internists were surveyed. Results were analyzed in 2007 and 2008. RESULTS: Response rates were 65% for family physicians and 79% for general internists. Thirty-one percent of physicians reported assessing most or all adult patients for hepatitis B risk factors and vaccinating patients identified as high risk. Perceived barriers to hepatitis B vaccination included patients not disclosing high-risk behaviors, lack of adequate reimbursement for vaccination, and feeling too pressed for time to assess risk factors. Most surveyed physicians were very (47%) or somewhat (38%) supportive of using standing orders for hepatitis B vaccination in their practices. However, staff time constraints and patient unwillingness to disclose sensitive information to staff were perceived as barriers to using standing orders by a majority of respondents. CONCLUSIONS: In a national survey, less than one third of primary care physicians reported routinely assessing for and vaccinating adults with hepatitis B risk factors. This finding suggests that new strategies for adult hepatitis B vaccination in primary care settings are needed. Most physicians supported using standing orders for vaccination, but barriers were anticipated.

Hepatitis A vaccination coverage among adults aged 18-49 years in the United States.

BACKGROUND: Hepatitis A is the most common type of hepatitis reported in the United States. Prior to hepatitis A vaccine introduction in 1996, hepatitis A incidence followed a cyclic pattern with peak incidence occurring every 10-15 years. During 1980-1995, between 22,000 and 36,000 hepatitis A cases were reported annually. Since 1996, hepatitis A vaccination recommendations have included adults at risk for infection and children living in communities with the highest disease rates. This study provides the first national estimates of self-reported hepatitis A vaccination coverage among persons aged 18-49 years in the United States. METHODS: We analyzed the 2007 National Immunization Survey-Adult (NIS-Adult) data with restrictions to individuals aged 18-49 years. National estimates of hepatitis A vaccination coverage were calculated based on self-report and multivariable logistic regression analysis was used to identify factors independently associated with hepatitis A vaccination status. RESULTS: Among adults aged 18-49 years, 12.1% (95% confidence interval, CI=9.9-14.8%) had received two or more doses of hepatitis A vaccine in 2007. Hepatitis A vaccination coverage was significantly higher among adults aged 18-29 years (15.6%) and adults aged 30-39 years (12.9%) compared with adults aged 40-49 years (8.3%). Coverage was significantly lower for Hispanics (7.1%) compared with non-Hispanic whites (12.5%). Characteristics independently associated with a higher likelihood of hepatitis A vaccination among persons aged 18-49 years included younger age groups, persons at or above poverty level, persons with public medical insurance, and persons who received influenza vaccination in the past season. CONCLUSIONS: In 2007, self-reported hepatitis A vaccination coverage among adults aged 18-49 years was 12.1%. These data provide the first national hepatitis A vaccination coverage estimates among adults and are very important in planning and implementing strategies for increasing hepatitis A vaccination coverage among adults at risk for hepatitis A.

Prevalence of infection with hepatitis B and C viruses and co-infection with HIV in three jails: a case for viral hepatitis prevention in jails in the United States.

Hepatitis B vaccination and targeted testing for hepatitis C virus (HCV) are recommended for jails with medical services available. This study estimates hepatitis B virus (HBV) and HCV infection prevalence among jail inmates, since most previous studies have been conducted among prison inmates. Prison and jail populations differ: jails hold a wide spectrum of persons for an average of 10-20 days, including persons awaiting arraignment, trial, conviction, or sentencing, while prisons typically hold convicted criminals for at least 1 year. A stratified random sample of sera obtained during routine syphilis testing of inmates entering jails in Chicago (March-April 2000), Detroit (March-August 1999), and San Francisco (June 1999-December 2000) was tested for serologic markers of HBV and HCV infection. All sera had been previously tested for antibody to HIV (anti-HIV). A total of 1,292 serum samples (12% of new inmates) was tested. Antibody to HCV (anti-HCV) prevalence was 13%. Antibody to hepatitis B core antigen (anti-HBc) prevalence was 19%, and hepatitis B surface antigen (HBsAg) prevalence was 0.9%; 12% had serologic evidence of hepatitis B vaccination. Hispanics had high rates of chronic HBV infection (3.6% HBsAg positive) along with Asians (4.7% HBsAg positive). Among HIV-infected persons, 38% were anti-HCV positive and 8.2% were HBsAg positive. Anti-HBc positivity was associated with anti-HCV positivity (aOR=4.58), anti-HIV positivity (aOR=2.94), syphilis infection (aOR=2.10), and previous incarceration (aOR=1.78). Anti-HCV-positivity was associated with anti-HBc positivity (aOR=4.44), anti-HIV-positivity (aOR=2.51), and previous incarceration (aOR=2.90). Jail entrants had high levels of HCV and HBV infection and HIV co-infection; HBV prevalence was comparable to previous prison studies, and HCV prevalence was lower than prison studies. Hispanics had an unexpectedly high rate of chronic hepatitis B infection and had the lowest rate of hepatitis B vaccination. The finding that hepatitis B vaccination coverage among jail entrants is lower than the general population, despite this population's increased risk for infection, highlights the need to support vaccination in jail settings.