Randomized Clinical Trial
Randomized Clinical Trial
lthough hepatitis A virus (HAV) and hepatitis B virus (HBV) infections are vaccine-preventable diseases, few homeless parolees coming out of prisons and jails have received the hepatitis A and B vaccination series.
Objectives
The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of three levels of peer coaching and nurse-delivered interventions was compared at 12-month follow up: (a) intensive peer coaching and nurse case management (PC-NCM); (b) intensive peer coaching (PC) intervention condition, with minimal nurse involvement; and a (c) usual care (UC) intervention condition, which included minimal PC and nurse involvement. Further, we assessed predictors of vaccine completion among this targeted sample.
Methods
A randomized control trial was conducted with 600 recently paroled men to assess the impact of the three intervention conditions (PC-NCM vs. PC vs. UC) on reducing drug use and recidivism; of these, 345 seronegative, vaccine-eligible subjects were included in this analysis of completion of the Twinrix HAV/HAB vaccine. Logistic regression was added to assess predictors of completion of the HAV/HBV vaccine series and chi-squared analysis to compare completion rates across the three levels of intervention.
Results
Vaccine completion rate for the intervention conditions were 75.4% (PC-NCM), 71.8% (PC), and 71.9% (UC) (p =. 78). Predictors of vaccine noncompletion included being Asian and Pacific Islander, experiencing high levels of hostility, positive social support, reporting a history of injection drug use, being released early from California prisons, and being admitted for psychiatric illness. Predictors of vaccine series completion included reporting six or more friends, recent cocaine use, and staying in drug treatment for at least 90 days.
Discussion
Findings allow greater understanding of factors affecting vaccination completion in order to design more effective programs among the high-risk population of men recently released from prison and on parole.
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With 1.6 million men and women behind bars, the United States (U.S.) has one of the largest numbers of incarcerated persons when compared to other nations (Pew Charitable Trusts, 2008). In California, over 130,000 are in custody and over 54,000 are on parole (California Department of Corrections and Rehabilitation, 2013b). Incarcerated populations are at significant risk for homelessness. When compared to the general population, those who were in jail were more likely to be homeless (Greenberg & Rosenheck, 2008). In one study, homeless inmates were more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, and a lack of personal assets (Greenberg & Rosenheck, 2008).
Globally, incarcerated populations encounter a host of public health care issues; two such issues—hepatitis A virus (HAV) and hepatitis B virus (HBV) diseases—are vaccine preventable. In addition, viral hepatitis disproportionately impacts the homeless due to increased risky sexual behaviors and drug use (Stein, Andersen, Robertson, & Gelberg, 2012), along with substandard living conditions (Hennessey, Bangsberg, Weinbaum, & Hahn, 2009). Other risk factors include, but are not limited to, injection drug use (IDU), alcohol use and older age, which place the population at risk for being seropositive (Stein et al., 2012).
As a member of the hepatovirus family, HAV is primarily transmitted via the fecal-oral route (Zuckerman, 1996). The rate of acute hepatitis in the US is 0.5 per 100,000 (Centers for Disease Control and Prevention, 2010). While the rate among paroled populations is hard to ascertain, data suggest that HAV infection is related to unsanitary living conditions, i.e., poor water sanitation (World Health Organization, 2014), for which homeless populations are at risk.
A member of the hapdnavirus family, HBV (Immunization Action Coalition, 2013; Zuckerman, 1996) disproportionately burdens homeless (Nyamathi, Liu, et al., 2009; Nyamathi, Sinha, Greengold, Cohen, & Marfisee, 2010) and incarcerated populations (Immunization Action Coalition, 2013; Khan et al., 2005), leading to fulminant liver failure, chronic liver disease, hepatocellular carcinoma, and death (Rich et al., 2003). HBV can be transmitted through unprotected sexual activity, needle sharing, IDU (Diamond et al., 2003; Maher, Chant, Jalaludin, & Sargent, 2004), and percutaneous blood exposure. National prevalence statistics indicate that HBV affects between 13% to 47% of U.S. prison inmates (Centers for Disease Control and Prevention, 2004). Illicit drug use is a major contributor to incarceration and homelessness among ex-offenders (McNeil & Guirguis-Younger, 2012; Tsai, Kasprow, & Rosenheck, 2014), placing ex-offenders who use drugs at high risk for HBV infection.
Despite the availability of the HBV vaccine, there has been a low rate of completion for the three-dose core of the accelerated vaccine series (Centers for Disease Control and Prevention, 2012). Among incarcerated populations, HBV vaccine coverage is low; in a study among jail inmates, 19% had past HBV infection, and 12% completed the HBV vaccination series (Hennessey et al., 2009). While HBV vaccination is well accepted behind bars—due to a lack of funding and focus on prevention as a core in the prison system—few inmates may complete the series (Weinbaum, Sabin, & Santibanez, 2005). In addition, prevention may not be a priority for those who are struggling with managing mental health, drug use, and dependency issues, along with the need to meet basic necessities (Nyamathi, Shoptaw, et al., 2010). Authors contend that while the HBV vaccine is cost effective, it is underutilized among high-risk (Rich et al., 2003) and incarcerated populations (Hunt & Saab, 2009).
