Reaching the "hard-to-reach" adult with immunizations

Background: Hepatitis A (HAV) & B (HBV) viruses infect 90,000 Americans annually and 1.25 million chronically. CDC recommends HBV and HAV vaccination for high-risk adults including those with multiple sexual partners, MSM, and injection drug users and also for those with chronic liver disease (including hepatitis C (HCV)). Now, 25 years since introduction of the vaccine, high risk adults still account for 70% of new HBV cases annually. High-risk adults are often poor, un- or underinsured, and have histories of stigmatized behaviors and are labeled “hard-to-reach”. In spite of the label, 60% of newly HBV infected adults had been in a setting where vaccination is possible during the previous year. Methadone maintenance program (MMP) clients have high-risk practices, interact with other drug users and HCV infection is common (40-80%). Most clients, therefore, should be vaccinated. Fewer than 24% of Philadelphia's 5,000 publically supported MMP clients are protected against HBV infection. We describe a mostly volunteer program designed to immunize MMP clients against HAV and HBV.

Methods: HepTREC, a community-based organization became a provider within Philadelphia Department of Public Health's Vaccine for Adults at Risk (VFAAR) program. By meeting program criteria and on-going program obligations, free vaccine is provided. Supplies were purchased with donated funds. Volunteer nurses and pharmacists administered vaccine and students assisted with administrative records. Since 2006, twenty immunization sessions were held in an MMP. All active clients (average census: 340) were eligible.

Results: Clients were enthusiastic participants in the immunization project, often on queue prior to 6 am start. Despite having health insurance, typically Medicaid, few received HAV or HBV vaccine from their primary care providers (PCPs). Approximately 10% received part of the vaccine series at jail or local syringe exchange. To date, 449 clients received 974 doses of vaccine. MMP discharge was common (109 before vaccine series completion). Another 57 client are not yet eligible for final doses. For those eligible, vaccine series completion rate is 83%. Clients reported hepatitis vaccination prompted the first hepatitis discussion with PCPs. Immunization also prompted other preventive actions such as influenza vaccination and cancer screenings. Volunteers gained valuable experience working with disadvantaged and stigmatized populations.

Conclusions: Initiating preventive care at convenient locations can make the “hard-to-reach” accessible and engaged. Immunizations can be provided at very low cost by coordinating interested stakeholders. The engagement benefits health professional sand health-professions students and improved patient-provider communications and reception of additional preventive services.