Economic benefits of hepatitis B vaccination at sexually transmitted disease clinics in the U.S.

OBJECTIVE: This study assessed the long-term economic implications of a national program to vaccinate all adults treated at sexually transmitted disease (STD) clinics in a single year. METHODS: A model was developed to track the long-term disease outcomes and costs among a hypothetical cohort of 2 million STD clinic clients accessing services in one year, using data from published sources and demonstration projects at STD clinics in San Diego (California), Illinois, and Denver (Colorado). The model estimated net economic benefits of a routine hepatitis B vaccination policy at STD clinics nationwide compared with no vaccination. RESULTS: Without a vaccination program, an estimated 237,021 new hepatitis B virus (HBV) infections would occur over the lifetimes of the 2 million STD clinic clients seen in a single year. HBV-related medical costs and productivity losses would be $1.6 billion. In a national program for routine vaccination at STD clinics, 1.3 million adults would be expected to receive at least one vaccine dose, and an estimated 45% of the new HBV infections expected without vaccination would be prevented. The vaccination program would cost $138 million, HBV infections occurring despite the program would cost $878 million, and clients' time and travel would cost $45 million. The net economic benefit (savings) of routine vaccination would be $526 million. If the indirect costs of lost productivity due to HBV infection are not considered, routine vaccination would have a net cost of $28 million. CONCLUSIONS: Estimates from this model suggest a national program for routine hepatitis B vaccination of adults at STD clinics would be a cost saving to society.

Hepatitis B vaccination in six STD clinics in the United States committed to integrating viral hepatitis prevention services.

OBJECTIVES: Hepatitis B vaccination is recommended for clients of sexually transmitted disease (STD) clinics. The Healthy People 2010 goal is for 90% of STD clinics to offer hepatitis B vaccine to all unprotected clients. This report describes hepatitis B vaccination trends in six STD clinics in the United States and discusses implications for policy and practice. METHODS: We conducted a retrospective study in six STD clinics to evaluate hepatitis B vaccination. We collected data on client visits and hepatitis B vaccinations for the period 1997-2005. To compare clinics, we calculated vaccination rates per 100 client visits. We interviewed staff to explore factors associated with hepatitis B vaccination trends. RESULTS: STD clinic client visits ranged from 2,883 to 23,109 per year. The median rate of hepatitis B vaccination was 28 per 100 client visits. Vaccination rates declined in all six clinics in later years, which was associated with eligibility restrictions caused by fiscal problems and increasing levels of prior vaccination. The median rate of vaccine series completion was 30%. Staff cited multiple provider- and client-level barriers to series completion. CONCLUSIONS: This study shows that STD clinics can implement hepatitis B vaccination and reach large numbers of high-risk adults. Adequate funding and vaccine supply are needed to implement current federal recommendations to offer hepatitis B vaccine to adults seen in STD clinics and to achieve the Healthy People 2010 objective.

The costs and impacts of testing for hepatitis C virus antibody in public STD clinics.

OBJECTIVES: To estimate the cost and cost-effectiveness of testing sexually transmitted disease (STD) clinic subgroups for antibodies to hepatitis C virus (HCV). METHODS: HCV counseling, testing, and referral (CTR) costs were estimated using data from two STD clinics and the literature, and are reported in 2006 dollars. Effectiveness of HCV CTR was defined as the estimated percentage of clinic clients in subgroups targeted for HCV antibody (anti-HCV) testing who had a true positive test and returned for their test results. We estimated the cost per true positive injection drug user (IDU) who returned for anti-HCV test results and the cost-effectiveness of expanding HCV CTR to non-IDU subgroups. RESULTS: The estimated cost per true positive IDU who returned for test results was $54. The cost-effectiveness of expanding HCV CTR to non-IDU subgroups ranged from $179 to $2,986. Our estimates were most sensitive to variations in HCV prevalence, the cost of testing, and the rate of client return. CONCLUSIONS: Based on national data, testing IDUs in the STD clinic setting is highly cost-effective. Some clinics may find that it is cost-effective to expand testing to non-IDU men older than 40 who report more than 100 lifetime sex partners. STD clinics can use study estimates to assess the feasibility and desirability of expanding HCV CTR beyond IDUs.

Low prevalence of hepatitis C virus antibody in men who have sex with men who do not inject drugs.

OBJECTIVE: It is well documented that injection drug users (IDUs) have a high prevalence of antibodies to hepatitis C virus (HCV). Sexual transmission of HCV can occur, but studies have shown that men who have sex with men (MSM) without a history of injection drug use are not at increased risk for infection. Still, some health-care providers believe that all MSM should be routinely tested for HCV infection. To better understand the potential role of MSM in risk for HCV infection, we compared the prevalence of antibody to HCV (anti-HCV) in non-IDU MSM with that among other non-IDU men at sexually transmitted disease (STD) clinics and human immunodeficiency virus (HIV) counseling and testing sites in three cities. METHODS: During 1999-2003, public health STD clinics or HIV testing programs in Seattle, San Diego, and New York City offered counseling and testing for anti-HCV for varying periods to all clients. Sera were tested using enzyme immunoassays, and final results reported using either the signal-to-cutoff ratio or recombinant immunoblot assay results. Age, sex, and risk information were collected. Prevalence ratios and 95% confidence intervals were calculated. RESULTS: Anti-HCV prevalence among IDUs (men and women) was between 47% and 57% at each site, with an overall prevalence of 51% (451/887). Of 1,699 non-IDU MSM, 26 (1.5%) tested anti-HCV positive, compared with 126 (3.6%) of 3,455 other non-IDU men (prevalence ratio 0.42, 95% confidence interval 0.28, 0.64). CONCLUSION: The low prevalence of anti-HCV among non-IDU MSM in urban public health clinics does not support routine HCV testing of all MSM.

Poliomyelitis outbreaks in Angola genetically linked to India: risk factors and implications for prevention of outbreaks due to wild poliovirus importations.

We conducted an investigation of two outbreaks of poliomyelitis in Angola during 2007-2008 due to wild poliovirus (WPV) genetically linked to India. A case-control study including 27 case-patients and 76 age- and neighborhood-matched control-subjects was conducted to assess risk factors associated with paralytic poliomyelitis, and epidemiologic links to India were explored through in-depth case-patient interviews. In multivariable analysis, case-patients were more likely than control-subjects to be undervaccinated with fewer than four routine doses of oral poliovirus vaccine (adjusted matched odds ratio [aMOR], 4.1; 95% confidence interval [CI], 1.2-13.6) and have an adult household member who traveled outside the province of residence in the 2 months preceding onset of paralysis (aMOR, 3.2; 95% CI, 1.2-8.6). No epidemiologic link with India was identified. These findings underscore the importance of routine immunization to prevent outbreaks following WPV importations and suggest a possible role of adults in sustaining WPV transmission.

Hepatitis C prevention programs: assessment of local health department capacity.

Hepatitis C virus (HCV) infection is the most common bloodborne infection in the United States. To determine the capacity of local health departments to respond to concerns about HCV, local health officers were surveyed regarding HCV programs and needs. Of 612 respondents, fewer reported offering HCV services (education, counseling, testing) compared with those for HIV. Most respondents reported that technical assistance would be needed for HCV services and that such services should be integrated into existing HIV programs. Many local health departments may be unprepared for a growing need for public HCV services; integrated HCV-HIV programs should be considered.

SARS surveillance during emergency public health response, United States, March-July 2003.

In response to the emergence of severe acute respiratory syndrome (SARS), the United States established national surveillance using a sensitive case definition incorporating clinical, epidemiologic, and laboratory criteria. Of 1,460 unexplained respiratory illnesses reported by state and local health departments to the Centers for Disease Control and Prevention from March 17 to July 30, 2003, a total of 398 (27%) met clinical and epidemiologic SARS case criteria. Of these, 72 (18%) were probable cases with radiographic evidence of pneumonia. Eight (2%) were laboratory-confirmed SARS-coronavirus (SARS-CoV) infections, 206 (52%) were SARS-CoV negative, and 184 (46%) had undetermined SARS-CoV status because of missing convalescent-phase serum specimens. Thirty-one percent (124/398) of case-patients were hospitalized; none died. Travel was the most common epidemiologic link (329/398, 83%), and mainland China was the affected area most commonly visited. One case of possible household transmission was reported, and no laboratory-confirmed infections occurred among healthcare workers. Successes and limitations of this emergency surveillance can guide preparations for future outbreaks of SARS or respiratory diseases of unknown etiology.