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RESEARCH AND PRACTICE |
Paula J. Lum is with the Positive Health Program, Department of Medicine, University of California, San Francisco, and the San Francisco General Hospital. Kristen C. Ochoa, Judith A. Hahn, Jennifer L. Evans, and Andrew R. Moss are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Kimberly Page Shafer is with the Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco.
Correspondence: Requests for reprints should be sent to Paula J. Lum, MD, MPH, Box 0874, University of California, San Francisco, San Francisco, CA 94143-0874 (e-mail: plum{at}php.ucsf.edu).
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INTRODUCTION |
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 TOP INTRODUCTION METHODSRESULTSDISCUSSIONReferences |
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We combined cash incentives and street outreach with flexible immunization schedules to improve HBV vaccine completion in young injectors in San Francisco. We examined factors associated with vaccine completion and observed postvaccination antibody responses in completers.
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METHODS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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A 20-µg intramuscular dose of recombinant DNA hepatitis B vaccine was administered at enrollment. Participants were instructed to return in 1 to 2 months for the second dose and then at 4 to 6 months for the third dose; they received $10 cash each time. Street-based outreach workers began delivering follow-up reminders 3 weeks after the first vaccine dose and again 11 weeks after the second dose.
We measured postvaccination anti-HBs seroconversion at 4 weeks after the third dose. We measured vaccine series completion and conducted bivariate analyses of variables associated with vaccine completion. We conducted a multiple logistic regression analysis of significant variables (P < .10) and other variables of interest or potential confounders.
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RESULTS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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). Most were new to San Francisco and unstably housed. During the prior year, 57% had been incarcerated. HIVpositive test results were found in 0.6%; 34% were anti-HCV positive. Most were frequent heroin injectors, and 76% attended syringe exchange programs in the last 30 days (Table 2). Thirty percent were gay or bisexual, and 8% had traded sex for money or drugs in the last 30 days.
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Vaccine completers were more likely to have lived in San Francisco for 3 or more months, to have received prior HIV testing, and to have anti-HCV-positive test results (Table 1
). Completers were more likely to inject drugs daily, to attend syringe exchange programs, and to have had sex with another IDU (Table 2). They were less likely to receive new needles from friends ("kickdowns") or to purchase needles from a pharmacy. Completers also were more likely to report that they could rely on outreach workers for social support and marginally more likely to report that they could rely on syringe exchange program staff (Table 3).
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Vaccine Response
Protective vaccine responses (anti-HBs 
10 mIU/mL) were observed in 38 of 49 (78%) completers, including 12 of 17 (71%) completers who were anti-HCV positive and 26 of 32 (81%) who were anti-HCV negative (OR = 0.55; 95% CI = 0.12, 2.82).
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DISCUSSION |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Geographic stability, HIV testing, reliance on outreach workers, and syringe sources were independently associated with vaccine completion. Young IDUs residing longer in San Francisco may have more stable lifestyles, making a 6-month intervention more feasible. Had this intervention been limited to those living in San Francisco for 3 months or more, completion would have been 58%. Young IDUs who can rely on outreach workers may have greater engagement with social service agencies. Their vaccine adherence underscores the important work of these organizations. Immunizations also may be more acceptable to injectors, who identify with a drug culture and engage in other prevention activities, such as HIV testing and syringe exchange programs. Indeed, 30 of 36 (83%) syringe exchange program–recruited participants in New York completed the vaccine series.19 Less established injectors may not recognize their high risk of infection and may think that immunizations are unwarranted.
Only 78% of the vaccine completers underwent anti-HBs seroconversion, compared with 99% reported by vaccine manufacturers.27 These figures raise concerns about blunting of young injectors’ immune responses. Suboptimal responses (58%–76%) have been noted among IDUs elsewhere.28,29 Although higher immunogenicity is associated with younger age, young IDUs are more likely than other young people to have poorer health and altered immunity. We observed a lower vaccine response among participants who were anti-HCV positive, but numbers were too small for significance. Other studies, however, have suggested that HCV infection may diminish the HBV vaccine response.30–32
Strategies to improve HBV vaccine completion and response in young IDUs are urgently needed, given the high incidence of co-infection with HBV and HCV10,17,33–35 and of accelerated liver damage in co-infected subjects.36–40 Higher vaccine doses (40 µg) and accelerated schedules have been used successfully among hemodialysis patients41 and alcoholic patients42 and may be effective for young IDUs. Young injectors are a challenging population in which to implement interventions aimed at preventing blood-borne infections. We suggest that a combination of street outreach and financial incentives may be important components of immunization programs for young injectors in other cities.
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Acknowledgments |
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We gratefully acknowledge the dedication of the UFO Study field staff and the street outreach efforts of Rachel McLean, Ivy McClelland, and Ben Sizemore from the Haight Ashbury Youth Outreach Team. We are also indebted to Drs Susan Fernyak and Mitch Katz of the San Francisco Department of Public Health for their generous contribution of hepatitis A and B virus vaccines. This brief is dedicated to the memory of Jennifer Hopkins.
Human Participant Protection
The study was approved by the Committee on Human Research at the University of California, San Francisco.
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Footnotes |
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P. J. Lum designed and conducted the study, analyzed and interpreted the data, and wrote the brief. K. C. Ochoa participated in the design and execution of the study and the interpretation of the data. J. A. Hahn and J. L. Evans participated in the statistical analysis and interpretation of the data. K. Page Shafer and A. R. Moss participated in the design of the study, the interpretation of the data, and the revision of the brief.
Accepted for publication February 9, 2002.
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References |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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