Gunn, Robert A. MD, MPH*†; Weinberg, Michelle S. MD, MPH*†; Borntrager, Denise BSc†; Murray, Paula J. MPH†
From the *Centers for Disease Control and Prevention, Atlanta, Georgia; and the †Health and Human Services Agency, San Diego, California
The authors thank Rita Perry, Jody Thomas, and Craig Sturak for manuscript preparation. This research was supported in part by an appointment (Dr. Gunn) to the Research Participation Program at the Centers for Disease Control and Prevention, National Center for HIV, Sexually Transmitted Diseases and Tuberculosis Prevention, administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and the CDC.
Correspondence: Robert A. Gunn, MD, MPH, STD Control Officer, HIV, STD and Hepatitis Prevention Branch, 3851 Rosecrans Street M/S P511B, San Diego, CA 92110. E-mail: email@example.com.
Received for publication July 27, 2005, and accepted November 9, 2005.
Background: Adults with chronic hepatitis B virus (HBV) infection are usually the source of infection for persons who acquire sexually transmitted HBV infection. Vaccinating sex- and needle-sharing partners is recommended.
Goal: To evaluate the usefulness of a syphilis model partner notification (PN) service for high-risk persons with chronic HBV infection.
Study Design: Locatable partners were offered serologic testing and HBV vaccination.
Results: Of 190 eligible case patients, 129 (68%) were interviewed, which included 47 men who have sex with men (MSM), 26 who reported injecting drug use (IDU), and 12 who were MSM and injected drugs. Among the 129 interviewed, 85 (66%) reported having ≥1 recent sex partner, 46 (36%) provided locating information for 47 partners, 38 partners accepted PN services, 15 were not immune, and 14 (7% of total eligible case patients) started and 9 completed the HBV vaccine series. Overall, 15% of case patients were also hepatitis C positive, and 29% were HIV infected. PN services cost was estimated at $1472 per vaccinee.
Conclusion: High-risk persons with chronic HBV infection provided few names or locating information for their partners, and the proportion eligible for vaccination was low. An integrated approach that provides hepatitis C screening, human immunodeficiency virus testing, and referral might be more useful and should be evaluated.
HEPATITIS B VIRUS (HBV) is a blood-borne and sexually transmitted virus that is acquired by percutaneous or mucosal exposure to blood and other body fluids of an infected person. Since persons with asymptomatic chronic HBV infection are usually the source of infection for persons who acquire HBV infection in adult life, vaccinating sex- and needle-sharing partners of those chronically infected persons is recommended.1–3 However, few health departments have partner notification (PN) programs that provide screening or vaccination for partners of high-risk persons with chronic HBV infection. Recent data also suggest that some community physicians may not be identifying and vaccinating at-risk partners of their patients with chronic HBV infection.4
PN has been used as a public health approach to prevent and control sexually transmitted diseases (STDs) for many decades.5,6 Recently, PN has been provided for human immunodeficiency virus (HIV)-infected persons, with variable success.7,8 Because PN for high-risk persons with HBV infection has not been a common practice, a PN program was initiated and evaluated in San Diego, CA, during the period March 1999 to June 2000.
A case patient with chronic HBV infection was defined as a person who tested hepatitis B surface antigen (HBsAg) positive and had either a negative IgM antibody test to hepatitis B core antigen (IgM anti-HBc) or no recent acute illness consistent with acute hepatitis B. Persons with chronic HBV infection were identified through morbidity reports, mostly from laboratories, sent to the San Diego County Health Department. In order to focus on the sex- and needle-sharing partners of persons most likely to be at high risk for transmitting hepatitis B infection, such as men who have sex with men (MSM), injecting drug users (IDUs), and persons with multiple sex partners, eligible case patients were limited to persons ages 15–45 years, living in the high-risk STD area of San Diego, and non-Asian/Pacific Islander surname. The high-risk area was composed of 2 contiguous regions (Central and South, combined population 932,144; 28% white, 46% Hispanic, 9% black, and 17% other) which accounted for much of the STD morbidity in San Diego. Persons with Asian/Pacific Islander surnames were not included because they most likely acquired their infection perinatally or during childhood, were less likely to be involved in high-risk sex and needle sharing,9 and their partners were more likely to be receiving notification and vaccination services from their providers.4 Pregnant women with HBV infection were also not included, because they were enrolled in a health department perinatal HBV prevention program. Eligible case patients were classified as high risk if they were MSM, IDUs, exchanged sex for drugs or money, had ≥15 lifetime sex partners, had ≥2 sex partners in the last 6 months, or ≥2 STDs in the last 5 years. Case patients without any of these characteristics were classified as low risk.
Communicable disease investigators (CDIs) interviewed and offered PN services to eligible case patients. Using the standard STD PN protocol, CDIs asked about partners during the 1-month period before their recent diagnosis of chronic HBV infection. The exposure period was limited to 1 month to focus on recent partners that might have ongoing exposure and would benefit most from HBV vaccination. A partner (contact) index was calculated as the number of named and potentially locatable partners per case interviewed.
Hepatitis B screening and vaccination were offered at no cost to all sex- and needle-sharing partners at the county STD clinic. CDIs recorded the number of telephone calls and field visits. To compute a cost estimate of these PN services, each telephone call was assigned 10 minutes and each field visit 120 minutes of work time. Data were analyzed using Epi-Info 6.0.
HBV Case Patients
During the 15-month evaluation period, >1000 HBsAg-positive test reports were received, and 190 case patients meeting the inclusion criteria were evaluated: 129 (68%) persons were interviewed, 42 (22%) could not be located, 15 (8%) refused, and 4 (2%) were not interviewed for other reasons. Case patients interviewed were mostly male (85%), ≥30 years of age (78%), and white (48%). Of the 129 cases, 89 (69%) were classified as high risk and included 47 (53%) MSM, 26 (29%) IDU, 12 (13%) MSM who also injected drugs, and 4 (5%) other. Overall, within the high-risk group, 13 (15%) persons had exchanged sex for money, 29 (33%) had ≥15 lifetime sex partners, and 28 (31%) rarely or never used condoms. In addition, among all interviewed cases (N = 129), 15% were coinfected with hepatitis C virus and 29% with HIV.
Among the 129 interviewed HBV case patients, 85 (66%) reported 136 sex partners during the 1-month period before being tested. No needle-sharing partners were reported, and 44 (34%) case patients reported having no sex partners during this 1-month period. High-risk case patients reported 110 partners (1.2 per high-risk case interviewed), and low-risk case patients reported 26 (0.7 per low-risk case interviewed). Of those 85 case patients reporting sex partners, only 46 (54%) accepted the CDIs’ offer to provide PN services (Table 1, Fig. 1). Low-risk case patients were more likely to accept the offer of PN services than high-risk case patients (73% [19/26] versus 46% [27/59], rate-ratio [RR] = 1.6, 95% confidence interval [CI] 1.1–2.3, P = 0.02). Overall, these 46 HBV case patients named and provided locating information for 47 partners, for a partner index of 0.36 (47/129). Among the 39 HBV case patients declining partner services, the most common reasons were case patient would inform partners (36%), partners were anonymous (18%), partners already vaccinated (13%), refused (16%), known anti-HBV positive (7%), and other (10%).
Of the 47 sex partners named, 38 (81%) received PN services. Of these 38 partners, 55% were female; 71% were >30 years of age; and 39% were white, 30% Hispanic, 11% black, 10% Asian Pacific-Islander, and 10% other/unknown. The risk characteristics were 32% MSM and 8% IDU; overall, 47% of the 38 partners never or rarely used condoms. Only 15 (39%) of the 38 partners were susceptible to HBV infection, and 14 started and 9 completed the vaccination series. One partner was newly identified with chronic HBV infection (HBsAg positive).
Disease investigators made 475 telephone calls to medical care providers, 543 calls to case patients and partners, and 243 field visits. The total amount of investigation work was estimated as 0.32 FTE (170 hours telephoning and 486 hours field visits = 656 hours ÷ 40 = 16.4 weeks or ∼0.32 FTE) which equated to ∼$19,200 for program salary costs ($60,000 annual salary and benefits × 0.32). Serology and vaccine costs were $1413 ($510 and $903, respectively). Total PN services cost was $20,613, or $1472 per vaccinee.
This evaluation of PN for persons with chronic hepatitis B virus infection, based on a STD syphilis model, demonstrated that many high-risk patients with chronic HBV infection could be contacted, but the partner index was only 0.36, indicating that only 1 potential locatable partner was named for each 3 HBV case patients interviewed. In contrast, in syphilis investigations partner indices are 3–4 times higher (approximately 1.0–1.5). This difference can be partially explained by the longer interview period during which partners can be named in a syphilis investigation, which ranges from 90 to 365 days (depending on syphilis stage), compared to only 30 days in this HBV PN evaluation. However, in addition, almost half (46%) of the HBV case patients with sex partners in the 1-month period did not accept PN services and did not provide names or locating information for those partners. The usefulness of PN for both syphilis and chronic HBV infection is limited by the high proportion of MSM case patients who often have only anonymous sex partners or prefer to inform their known partners without health department involvement.
There have been several evaluations of partner services for sex and household contacts of women with chronic HBV infection identified through perinatal screening programs.10–12 Acceptance of services has generally been high, and vaccination of a substantial proportion of susceptible sex partners has been accomplished. In one evaluation in Amsterdam, Netherlands, among 738 newly identified pregnant women (mostly immigrants) with chronic HBV infection, 1219 contacts were reported, 90% accepted vaccination, and, of those susceptible, 94% completed the vaccine series.10 This level of participation was much higher than observed in our study, mainly because the risk characteristics of the cases and partners differed considerably. Although not stated, many of the partners were most likely spouses and not members of high-risk groups. In this same city, an HBV vaccination outreach program for high-risk persons (MSM, IDUs, and sex workers) was moderately successful, but vaccine acceptance was lower (vaccination acceptance 42%, series completion 62%)13 compared to the perinatal program. Although this outreach program was directed to high-risk persons, it did not involve naming partners. In our study, the largest impact on the final outcome (vaccinating partners) was the fact that case patients who had sex partners did not accept partner services (46% did not accept services).
In addition to the low acceptance of PN by case patients, the impact of PN services was further limited because more than half (61%) of the partners who accepted PN were not eligible for vaccination, because they were already immune from previous HBV infection or vaccination. Considering the initial number of case patients requiring investigation (N = 190), the application of this service model resulted in only 14 (7%) persons starting the vaccine series, with an estimated cost of $1472 per vaccinee, which is costly compared to other preventive services.
Considering the current pressure of resurgent syphilis on STD field investigators, most STD program managers, based on this evaluation, would likely place HBV PN services low on their priority of intervention activities. However, evaluations of HBV PN in other communities are needed to definitively determine the usefulness of this service. In addition, considering that ≥15% of HBV case patients in this evaluation were also hepatitis C and/or HV positive, a comprehensive integrated approach that includes counseling, serologic screening, PN for all infections, and appropriate referral should be included in any future evaluation of PN services for high-risk persons with chronic HBV infection.
An alternative approach to PN services for preventing hepatitis B infection among adults is to identify high-risk populations and provide low- or no-cost vaccination services. This can be accomplished in a variety of settings, with success most likely in STD clinics,14 HIV counseling and testing sites, and drug rehabilitation programs.15 However, until more funding is available for vaccine purchase for high-risk adults, vaccination levels will remain below the optimum needed to prevent much of the transmission of hepatitis B virus infection that still occurs among high-risk adults in the United States.
1. Centers for Disease Control and Prevention. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United Sates through universal childhood immunization: recommendations of the Advisory Committee on Immunizations Practices (ACIP). MMWR Morb Mortal Wkly Rep 1991; 40:1–25.
2. Centers for Disease Control and Prevention. Update: recommendations to prevent hepatitis B virus transmission: United States. MMWR Morb Mortal Wkly Rep 1995; 44:574–575.
3. Centers for Disease Control and Prevention. Update: recommendations to prevent hepatitis B virus transmission: United States. MMWR Morb Mortal Wkly Rep 1999; 48:33–34.
4. Weinberg MS, Gunn RA, Mast EE, Gresham L, Ginsberg M. Preventing transmission of hepatitis B virus from people with chronic infection. Am J Prev Med 2001; 20:272–276.
5. Rothenberg RB, Potterat JJ. Partner notification for sexually transmitted diseases and HIV infection. In: Holmes KK, Sparling PF, Mardh P-A, Lemon SM, Piot P, Wasserheit JN, eds. Sexually Transmitted Diseases. New York, NY: McGraw-Hill, 1999:745–752.
6. Kohl KS, Farley TA, Ewell J, Scioneaux J. Usefulness of partner notification for syphilis control. Sex Transm Dis 1999; 26:201–207.
7. Fenton KA, Peterman TA. HIV partner notification: taking a new look. AIDS 1997; 11:1535–1546.
8. Toomey KE, Peterman TA, Dicker LW, Zaidi AA, Wroten JE, Carolina J. Human immunodeficiency virus partner notification: cost and effectiveness data from an attempted randomized controlled trial. Sex Transm Dis 1998; 25:310–316.
9. Nguyen MH, Keefe EB. Chronic hepatitis B and hepatitis C in Asian Americans. Rev Gasteroenterol Disord 2003; 3:125–134.
10. Steenbergen JEv, Baayen D, Peerbooms PGH, Coutinho RA, Hoek AVD. Much gained by integrating contact tracing and vaccination in the hepatitis B antenatal screening program in Amsterdam, 1992–1999. J Hepatol 2004; 40:979–985.
11. Richardson G, Evans MR, Westmoreland D. Hepatitis B immunization of household contacts: retrospective study of vaccine coverage. J Epidemiol Community Health 2001; 55:934–935.
12. Euler GL, Copeland J, Williams WW. Impact of four urban perinatal hepatitis B prevention programs on screening and vaccination of infants and household members. Am J Epidemiol 2003; 157:747–753.
13. Steenbergen JEV. Results of an enhanced-outreach programme of hepatitis B vaccination in the Netherlands (1998–2000) among men who have sex with men, hard drug users, sex workers and heterosexual persons with multiple partners. J Hepatol 2002; 37:507–513.
14. Centers for Disease Control and Prevention. Hepatitis B vaccination among high-risk adolescents and adults, San Diego, CA 1998–2001. MMWR Morb Mortal Wkly Rep 2002; 51:618–621.
15. Gunn RA, Lee MA, Callahan DB, Gonzales P, Murray PJ, Margolis HS. Integrating hepatitis, STD, and HIV services into a drug rehabilitation program. Am J Prev Med 2005; 29:27–33.