Prevalence and Correlates of Previous Hepatitis B Vaccination
and Infection Among Young Drug-users In New York City
S. Amesty Æ Æ D. C. Ompad Æ Æ S. Galea Æ Æ C. M. Fuller Æ Æ
Y. Wu Æ Æ B. Koblin Æ Æ D. Vlahov
Published online: 10 January 2008
? Springer Science+Business Media, LLC 2008
remains low among drug users. In 1997, ACIP made hep-
atitis B vaccine available for persons aged 0–18 years and
many states began requiring HBV vaccination for entry
into middle school; these programs might affect HBV
vaccination and infection rates in younger DUs. We were
interested in determining correlates of immunization
among younger (\25 years) and older (25 and older) DUs.
Methods: A community-based sample of 1,211 heroin,
crack, and cocaine users 18 or older was recruited from
Harlem and the Bronx. We assessed previous HBV
vaccination and infection and correlates using bivariate
analyses. Results: The sample was predominantly male
(74.0%), aged C25 years (67.1%) and Hispanic (59.9%). In
terms of socioeconomic status, 57.1% had less than a high
school education, 84.5% had been homeless in their life-
time, and 48.0% had an illegal main income source.
Among 399 DUs younger than 25 years of age, 30%
demonstrated serological evidence of previous vaccination,
49.9% were susceptible to HBV at baseline, and 20%
showed evidence of infection. In our model, previous HBV
infection and vaccination status were associated with being
22 years old or younger (AOR = 1.40 and 1.66). Com-
pared to susceptible individuals, those vaccinated were
significantly less likely to be born in other countries
(AOR = 0.50). Among 812 DUs 25 and older, 10.6%
demonstrated serological evidence of previous vaccination,
59.2% were susceptible to HBV at baseline, and 30.2%
showed evidence of infection. Conclusion: Existing inter-
ventions to increase HBV vaccination among adolescents
should target high risk groups.
Hepatitis B ? Substance use ? Vaccination
Hepatitis B virus (HBV) infection continues to be a major
public health concern in the 21st century, with an estimated
1.25 million Americans being chronic carriers and an
estimated 5,000 deaths from chronic liver disease each year
[1–5]. Parenteral transmission of HBV through injection
drug use practices accounts for more than half of all HBV
cases . Additionally, the prevalence of HBV infection
among injection drug users (IDUs) ranges between 40%
and 81% [7, 8].
College of Physicians and Surgeons, Center for Family and
Community Medicine, Columbia University, 630 W 168th
Street, New York, NY 10032, USA
D. C. Ompad (&) ? S. Galea ? C. M. Fuller ? D. Vlahov
Center for Urban Epidemiologic Studies, New York Academy
of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA
Department of Epidemiology, University of Michigan School
of Public Health, Ann Arbor, MI 48109, USA
C. M. Fuller ? B. Koblin ? D. Vlahov
Department of Epidemiology, Mailman School of Public Health,
Columbia University, 722 W 168th Street, New York, NY
Center for the Study of Hepatitis C, Weill Medical College
of Cornell University, 411 E 69th Street, Room KB200-A,
New York, NY 10021, USA
New York Blood Center, 63 W 87th Street, New York,
NY 10024, USA
J Community Health (2008) 33:139–148
An effective recombinant HBV vaccine has been avail-
able for more than 20 years. Introduced into the childhood
immunization schedule in the US in 1991 [9, 10], the HBV
vaccine has been recommended for a variety of individuals
including those at occupational risk of infection (e.g. health
care workers), men who have sex with men (MSM), sexu-
ally transmitted disease (STD) patients, and IDUs .
Despite these strategies to reduce HBV, the estimated
number of new hepatitis B infections was still 60,000 in
2004; adults accounted for 95% of the cases; the majority
registered among the 25–44 year old group, followed by the
15–24 year old and the older than 45 groups; in general,
vaccination rates remain low in adult high risk groups .
HBV vaccination is required for entry into middle school
in 37 of the 50 states and the District of Columbia since
1997 or later. In addition, in 1995, the Advisory Committee
on Immunization Practices (ACIP) recommended vaccina-
tion of all unvaccinated children 11 years of age and
younger, and in 1997, this recommendation was expanded
to all unvaccinated adolescents aged 18 and younger .
These mandates and recommendations should result in
higher vaccination rates in younger adults. However, some
adolescents and young adults in high risk groups, who
should have been part of the group covered by these rec-
ommendations and HBV vaccination programs have been,
and continue to be, missed by these vaccination programs
and catch-up schemes and thus remain susceptible to HBV.
This has been implied in studies of HBV and younger IDUs
and even lower vaccination rates have been reported in
studies of younger MSM aged 15–22 years, where vacci-
nation coverage is 9% despite 90% reporting regular access
to health care . Clearly, many adolescents are slipping
through the cracks and not receiving HBV vaccination.
In this study we aimed to compare the serologic prev-
alence and correlates of previous HBV infection and
vaccination among younger (less than 25 years old) and
older (25 and older) IDUs and NIDUs among new recruits
to a prospective study of young injection and non-injection
heroin, crack, and cocaine users in Harlem and the South
Bronx in New York City.
Potential participants were recruited for two ongoing
studies of NIDUs and IDUs using street outreach tech-
niques, as described elsewhere [14, 15]. Briefly, outreach
workers engaged drug users in conversations about ongo-
ing research at the research storefront at places in the
community where drugs were bought and/or used. Both
IDUs and NIDUs were recruited between 2000 and 2004.
Potential participants completed a screening demographic
interview. The IDU study was designed to study correlates
and predictors of hepatitis C infection and therefore tar-
geted young, recently initiated IDUs at risk for HCV
infection. Participants were eligible for the injector part of
the study if they were age 15–40 years and reported
injecting drug use of heroin or cocaine at least once in the
last 2 months but for no longer than 5 years. The NIDU
study was aimed at investigating correlates and predictors
of transition to injection drug use, and therefore recruited
young NIDUs. Participants were eligible for the non-
injector part of the study if they were age 15–40 years and
reported non-injecting drug use of heroin or cocaine at least
2–3 times in the last 2 months but for no longer than
10 years, and no history of injecting drug use. Participants
were reimbursed $20 for their participation. The study was
approved by the institutional review boards of the New
York Academy of Medicine and the New York Blood
Center. Informed consent was obtained from all study
participants and guidelines for human experimentation of
the US Department of Health and Human Services and the
authors’ institutions were followed in the conduct of this
Following informed consent, eligible participants com-
pleted a standardized, detailed risk behavior questionnaire
administered by trained interviewers. We asked about the
type, frequency, and duration of their drug use, and the use
and sharing of drug equipment. We also asked participants
about their vaccination and medical histories. The lack of
prior drug use by injection was confirmed during the
comprehensive interviewing process and by phlebotomists’
observations during venipuncture.
Demographic characteristics considered included age,
race, gender, socioeconomic status (SES), and ever being
homeless. Several variables were used to assess SES
including education, homelessness, main income source
(e.g. employed, illegal, or public assistance) and income. In
terms of risk behaviors, our analysis focused on drug use,
drug treatment and potential opportunities for exposure to
HBV through drug use behaviors (e.g. injection drug use)
and sexual partners (e.g. IDUs, MSM and hepatitis-infected
sex partners). The question regarding hepatitis-infected sex
partners did not differentiate between different hepatitides.
HBV Testing, Counseling, and Referrals
Following completion of the interview, all participants
were counseled about hepatitis B, hepatitis C, and HIV
140J Community Health (2008) 33:139–148
infection and had a blood specimen drawn for serologic
testing. Serology samples were tested for HBV, HCV and
HIV. HBV testing consisted of detection of Hepatitis B
surface antigen (HBsAg: Abbott Laboratories, Abbott Park,
IL), antibodies to hepatitis B surface antigen (anti-HBs:
Ortho Clinical Diagnostics, Inc, Raritan, NJ) and antibod-
ies to hepatitis B core antigen (anti-HBc: Ortho Clinical
Diagnostics Inc, Raritan, NJ). HCV antibodies were
detected by enzyme-linked immunosorbant assay (ELISA)
(Ortho HCV Version 2.0 ELISA). Sera that were reactive
on the first testing were retested in duplicate. Repeatedly
reactive samples were confirmed by strip immunoblot
assay (Chiron RIBA HCV 3.0 SIA). HIV antibodies were
detected using enzyme-linked immunosorbant assay (EIA)
for HIV types 1 and 2 (Abbott Laboratories, Abbott Park,
IL) with a confirmatory Western for HIV type 1 (Calypte
Biomedical Corporation, Alameda, CA).
Participants returned two to three weeks later to learn
their test results and receive referrals for medical care and
other health and social services. Participants who were
immune to HBV by previous infection or vaccination were
informed of their serostatus. Participants who were found
to be HBV susceptible were informed that they were HBV
negative and encouraged to receive vaccination through
one of our community partners, as has been described
We compared participants who had serologic evidence of
previous HBV vaccination (anti-HBs positive, HBsAg and
anti-HBc negative) or previous/current HBV infection
(HBsAg and/or anti-HBc positive) at baseline to those who
were susceptible to HBV at baseline (HBsAg, anti-HBs and
anti-HBc negative), stratified by age (younger than
25 years of age versus 25 and older). We described
demographic characteristics among the susceptible and
vaccinated groups, in addition to drug use and sexual
Bivariate analyses were conducted to examine demo-
graphic and risk behavior variables by vaccination status
using v2statistics. Covariates that were significantly asso-
ciated with vaccination status in bivariate analyses
(P\0.20) were entered into a final multivariate poly-
chotomous generalized logit model. Covariates that did not
remain significant in the model (P\0.05) were removed.
We also sought to determine the reliability of self-
reported vaccination among this population of substance
users. Using serological evidence of HBV vaccination
(serologic response to anti-HBs only) as the ‘‘gold stan-
dard,’’ we determined the specificity and sensitivity of self-
reported HBV vaccination.
Among the 1,211 subjects enrolled in the study, 26.8% had
serologic evidence of HBV infection, 56.2% were sus-
ceptible to HBV at baseline, and 17.0% demonstrated
serological evidence of previous vaccination. The preva-
lence of HBV infection among IDUs was 35.8%; however
the prevalence of HBV infection among NIDUs was not
inconsiderable at 22.7%. The sample was predominantly
male (74.0%), aged 25 and older (67.1%), heterosexual
(85.0%) and Hispanic (59.9%). In terms of socioeconomic
status, 57.1% had less than a high school education, 84.5%
had been homeless in their lifetime, and 48.0% had an
illegal main income source.
Because self-reported HBV vaccination was a signifi-
cant correlate of vaccination, we evaluated the reliability of
self-report in this population. Overall, approximately
27.7% of participants self-reported being previously vac-
cinated against HBV. Of those who self-reported having at
least one dose of HBV vaccine, 32.6% were anti-HBs
positive. The concordance between the serologic results
and self-report was high (73.8%). The sensitivity and
specificity for self-reported HBV vaccination was 48.5%
and 79.0%, respectively. Kappa statistic for comparison
between self-reported and serologic evidence of vaccina-
tion was 0.23.
HBV Among Participants Less Than 25 year Old
Among the 399 participants younger than 25 years of age,
50% were susceptible to HBV, 20% showed evidence of
infection, and 30% had serologic evidence of vaccination.
Participants younger than 25 years of age (Table 1) were
predominantly male (78.9%) and Hispanic (71.7%). About
one third of participants (30.5%) had a high school diploma
or equivalent, 82.6% had been homeless in their lifetime,
and 57.7% had an illegal main source of income. We
compared participants less than 25 years of age who were
susceptible to HBV to those who were vaccinated or
infected, based on serological findings at baseline with
respect to sociodemographic characteristics. Those with
evidence of HBV infection were more likely to be HIV and
HCV infected than those who were susceptible to or pre-
viously vaccinated for, HBV. Those with evidence of HBV
infection were more likely to have been born in Puerto
Rico than those vaccinated or susceptible.
by HBV serostatus. Eleven percent of NIDUs showed evi-
dence of HBV infection compared to 31% of IDUs. Those
infected with HBV were more likely to have been in a drug/
alcohol treatment program. Among IDUs, those infected
with HBV were more likely to inject daily and attend a
J Community Health (2008) 33:139–148141
shooting gallery (data not shown) and to have use heroin
daily in the last 6 months when compared to susceptible and
vaccinated participants. Although not statistically signifi-
cant, those who reported needle sharing were more likely to
be infected; however, 45.7% of susceptible IDUs reported
sharing needles and 34.3% of susceptible IDUs attended a
shooting gallery (data not shown).
In a final multivariable polychotomous logit model
(Table 3) with ‘‘uninfected/no serological evidence of
vaccine’’ as the reference, we found that both previous HBV
infection andvaccination were associated with HCV andHIV
seropositivity (AOR = 3.14 and 1.51 for HCV, and AOR
= 2.96 and 2.30 for HIV, respectively). Previous HBV infec-
oldoryounger (AOR = 1.40andAOR = 1.66,respectively).
Compared to susceptible individuals, those vaccinated
were significantly less likely to be born in other countries
(AOR = 0.50).
Table 1 Sociodemographic characteristics of drug users in Harlem and the South Bronx by serologic evidence of HBV vaccination, stratified by
Age\25 years Age = or[25 years
(n = 120) %
(N = 199) %
(n = 80) %
(n = 86) %
(N = 481) %
(n = 245) %
Main income source
Self-reported HBV vaccination
aP B 0.01
bP B 0.05
142J Community Health (2008) 33:139–148
HBV Among Participants 25 years of Age and Older
Among the 812 participants 25 years of age and older, 60%
were susceptible to HBV, 30% showed evidence of current
or past infection, and 10% had serologic evidence of vac-
cination. The sample was predominantly male (71%) and
Hispanic (54.1%). About half of the participants in this
group had a high school diploma or equivalent, and 43.2 %
had an illegal main source of income. Table 1 shows the
sociodemographic characteristics of drug users 25 years of
age and older by serologic evidence of HBV vaccination.
Those with evidence of previous HBV infection were more
likely to be heterosexual, homeless, to have an illegal
source of income, and to be seropositive for HCV and HIV
than those who were susceptible or vaccinated.
Table 2 describes drug use and sexual behavior stratified
by HBV serostatus. Of 210 NIDUs, 27% were found to
have evidence of previous HBV infection whereas 40% of
IDUs showed evidence of previous infection. As with those
younger under 25 years of age, those infected with HBV
were more likely to be injectors, inject drugs daily, attend a
shooting gallery (data not shown), than those vaccinated or
Table 2 Sexual and drug use behaviors of drug users in Harlem and the South Bronx by serologic evidence of HBV vaccination, stratified
Age\25 yearsAge = or[25 years
(n = 120) %
(N = 199) %
(n = 80) %
(n = 86) %
(N = 481) %
(n = 245) %
No 58.364.3 31.3a
Yes41.7 35.768.8 26.721.633.9
Drug or alcohol treatment
Alcohol use in last 6 months
Cocaine use in last 6 months
Crack use in last 6 months
Heroin use in last 6 months
Used NEP in last 6 months
Ever 42.028.644.452.2 47.149.4
IDU sex partner
Hepatitis positive sex partner
Yes6.72.5 3.87.04.8 8.2
aP B 0.01
bP B 0.05
J Community Health (2008) 33:139–148143
susceptible. Those who share needles were more likely to
be infected, but this was not statistically significant; how-
ever, 35% of susceptible IDUs reported sharing needles
and 24% of susceptible IDUs attended a shooting gallery
(data not shown). Although not statistically significant,
HBV infected individuals were also more likely to have
had a hepatitis-positive sex partner than those who were
vaccinated or susceptible.
In a final multivariable polychotomous logit model
(Table 4) with ‘‘uninfected/no serological evidence of vac-
was associated with being Black (AOR = 1.66), being
(AOR = 1.35), HCV seropositive (AOR = 2.00) and HIV
seropositive (AOR = 1.91). There were no significant cor-
relates of vaccination in this group, other than self-report.
Because of the low reliability of self-report in this popula-
(AOR = 1.37),being homosexual/bisexual
In this sample of recently initiated heroin, crack and
cocaine users in New York City, more than half had
Table 3 Generalized polychotomous logit model of HBV serostatus among 399 drug users of age younger than 25 years old
Crude odds ratio
Adjusted odds ratio
Crude odds ratio
Adjusted odds ratio
Age\22 years old 1.38
Puerto Rico 1.80
Table 4 Generalized polychotomous logit model of HBV serostatus among 812 drug users 25 years of age and older
Crude odds ratio
Adjusted odds ratio
Crude odds ratio
Adjusted odds ratio
Self-reported HBV vaccination1.53
144J Community Health (2008) 33:139–148
serologic susceptibility to HBV infection. Approximately
17% had been previously vaccinated for HBV, based upon
serologic evidence. This is similar to reports among drug
users in Seattle, Oakland, and New York City where
between 14% and 17% of IDUs had previously been vac-
cinated against HBV [17–19], but higher than rates
suggested in Baltimore in the late 1980 s . However,
the vaccination rates in Seattle and Oakland relied on self-
reported vaccination among IDUs as opposed to the sero-
logic testing used in this study, so comparisons should be
made with caution, given the low reliability of self-report.
As expected, younger drug users were more likely to
have been vaccinated . In our study, 30% of the par-
ticipants younger than 25 years of age showed serological
evidence of vaccination (Table 1), which is consistent with
the literature for this age group [18, 19]. Although the
prevalence of vaccination in younger IDUs is higher than
in older IDUs (10%), vaccination among younger adults
would be higher than 30%, considering existing programs
and recommendations from ACIP and the Centers for
Disease Control and Prevention (CDC). ACIP made hep-
atitis B vaccine available through the Vaccines for
Children program (VFC) for persons aged 0–18 years who
are eligible for VFC . Even though only one third of
the sample finished high school, many states require HBV
vaccination for entry into middle school since 1997.
Moreover, during 1993–2000, it is reported that hepatitis B
vaccination coverage for adolescents 13–15 years of age
increased from 0% to 67%, much higher than the 30%
vaccination rates we found among the less than 25 year old
group in 2006 . Ten years have passed since the 1997
ACIP recommendations for unvaccinated adolescents and
children 18 and younger. The vaccination programs, catch
up schemes, and mandates may have had an impact on the
higher vaccination rates seen among younger IDUs when
compared to older IDUs, but it does not explain the lower
than expected vaccination rates among the younger group.
In an attempt to better understand HBV vaccination rates
in this group, we looked at school drop out rates and age of
dropout,andwe foundnosignificantrelationshipwith HBV
vaccination (data not shown). Furthermore, participants less
than 25 years of age who were previously infected were
more likely to have been in a drug/alcohol treatment pro-
gram that those vaccinated or susceptible, which represents
a potential missed opportunity for vaccination. Of note,
54.8% of the susceptible participants younger than 25 have
have been vaccinated (Table 2).
We observed a significant relationship between place of
birth and HBV vaccination status in this younger group;
those born in the US were more likely to be vaccinated than
those born in other countries (Table 3). A small percentage
of participants were born outside of the US (9.9%). One
possible explanation for lower vaccination rates in the
foreign-born group is that many of these participants may
be recent immigrants from countries with different immu-
nization requirements for school entry than the US.
Another potential explanation for lower vaccination rates
in this group may have to do insurance status and access to
preventive health services. Lastly, health-seeking behaviors
may differ significantly in this group, possibly due to
variations in trust in the health care system and reliance on
alternative health care sources as part of different cultural
norms. Having said this, there were no racial/ethnic dis-
parities observed in terms of vaccination rates in this group
of younger IDUs.
Among the younger group, we still observed a signifi-
cant relationship between age and HBV status (Table 3);
those 22 years of age or younger were more likely to have
evidence of HBV infection than those older than 22 years
of age. It has been reported in the literature that young and
recently initiated injectors are higher risk for acquiring
blood-borne infections such as HCV and HBV due to
unsafe injecting behaviors . Our findings support this
conclusion from prior studies. We also found that previous
HBV vaccination was associated with being 22 years old or
younger, which may reflect that the younger participants in
the less than 25 year old group were more likely to have
been part of the childhood vaccination scheme.
Although coverage of HBV vaccine among health care
workers is about 65% [23, 24], vaccination coverage
among various acknowledged risk groups has been repor-
ted to be much lower. For example, coverage among MSM
ranges between 9% and 48% [13, 25–29], while coverage
among STD patients ranges between 11% and 14% [30,
31]. With prevalence of HBV infection being high among
drug users, and IDUs in particular, studies suggest limited
coverage of HBV vaccine; i.e. between 6 and 19% of IDUs
in general are vaccinated; higher rates, but lower than
expected, are reported among younger IDUs (11–32% of
IDUs younger than 24 years of age are vaccinated) [8, 18–
20, 27, 32, 33]. Our findings are consistent with the liter-
ature on vaccination, susceptibility to HBV, and HBV
infection rates among younger and older IDUs.
Vaccination rates in adults remain low for several rea-
sons: barriers to vaccination among high risk groups
include lack of access to resources (i.e. health care), dis-
comfort with the vaccines, mistrust in the medical system,
and poor hepatitis knowledge [2, 34–36]. It is also partly
due to the lack of national programs supporting infra-
structure and vaccine purchase for adults, resulting in a
high percentage of missed opportunities for vaccination in
drug treatment programs, syringe exchange programs
(SEPs), STD clinics, and jails or detention centers [11, 18,
37, 38]. Improving vaccination rates among younger and
older drug users is an important step towards reducing the
J Community Health (2008) 33:139–148145
societal burden of HBV. Previous studies have documented
HBV first dose vaccine acceptance rates among susceptible
IDUs in the United States between 3% and 81% (median
54%) [18, 37, 39], the higher vaccination and completion
rates being reported in SEPs, drug treatment programs, or
when monetary incentives were offered to participants; the
lowest vaccination acceptance rates were observed in
studies where participants were referred to clinics for
vaccination and/or did not receive monetary incentives
[18, 37, 40]. Currently, the description of vaccination
efforts among drug users have been limited to overall
vaccination and completion rates [36, 37, 40–43] and
immune response to the vaccine [41–44], with limited data
available describing the characteristics of those who have
In our study, those participants 25 years old and older
who had ever been in drug or alcohol treatment were sig-
nificantly more likely to have been vaccinated. Other
studies have reported similar results . As mentioned
previously, one of the barriers to vaccine acceptance is
poor knowledge of hepatitis B, and having participated in a
drug treatment program has been associated with enhanced
knowledge of hepatitis B . This may suggest that
education provided about hepatitis B in drug treatment
programs is effectively acquired and retained, and this
could minimize barriers to vaccine acceptance. Higher
rates of vaccination among those who have ever partici-
pated in drug and alcohol treatment programs may also be
due to vaccination services in treatment settings or may be
a proxy for being more likely to seek treatment. Because
we do not have data on where individuals were vaccinated,
this finding could not be explored further in this study.
However, a high percentage of participants who have been
in a drug/alcohol treatment programs were susceptible to
HBV (54.8%), which, as in the younger group, may rep-
resent missed opportunities for vaccination.
Approximately one fourth of the study sample had been
previously infected with HBV. IDUs were more likely to
have been HBV-infected than NIDUs (35.8% vs. 22.7%)
(Table 2). However, as this and previous studies have
demonstrated [45–47], HBV infection among NIDUs is not
negligible. Recent studies report that between 19% and
21.6% of NIDUs had been previously infected with HBV
[16, 38]; these rates are much higher than the 5% rate
found in the general population . Higher than expected
rates of infection can be also observed in the less than
25 year old group, where 11% of the NIDUs were HBV
infected. Our findings highlight the importance of NIDUs
in HBV transmission. NIDUs are at risk for HBV acqui-
sition due to risky sexual behavior [45, 47] and risky sexual
networks , and we cannot rule out the possibility of
transmission through risky non-injection drug using eti-
quette (such as sharing straws or hot pipes that abrade the
mucosal lining), and as other studies has shown, household
contact transmission [48, 49]. NIDUs are also at risk for
transition into injection drug use. Previous studies have
demonstrated that the period of transition from sniffing or
smoking to injection can be particularly risky, as the new
injector learns a new set of skills [50, 51] and becomes
acquainted with new social networks . During this
critical transition period, the new injector is at a particu-
larly high-risk for HBV, as well as HIV and HCV. It is
therefore imperative that non-injection users of heroin,
crack and cocaine be vaccinated for HBV.
Identifying as Black, homosexual/bisexual, and injec-
tion drug use were all associated with HBV infection.
Previous studies have demonstrated an increased risk for
HBV among IDUs  and homosexual/bisexual men .
A recent study examined HBV infection among veterans
with severe mental illness and reported higher rates of
HBV among Black veterans as compared to White veterans
that was associated with difference in rates of high risk
drug use and sexual behaviors . In order to evaluate
this, we investigated potential racial/ethnic differences
with respect to drug use and sexual behaviors. While
Blacks were significantly less likely to have injected drugs,
injected drugs at a younger age, inject drugs daily, share
needles, go to a shooting gallery, use cocaine and heroin
daily, and have sex with an IDU as compared to Hispanics
and Whites/Others, they were significantly more likely to
have used crack daily in the last six months and to have had
sex with an MSM (data not shown), and these two risk
behaviors are associated to previous HBV infection [2, 19].
Although this cannot completely explain the racial/ethnic
differences we observed, it does suggest that the risk
behaviors differ between the racial/ethnic groups. Another
possible explanation could be a higher prevalence of HBV
among the social networks of the Black participants,
although data were not available to examine this in detail.
We did ask about hepatitis-infected sex partners and did
not find any significant differences with respect to race.
This study also provided important insight into the
validity of self-reported HBV vaccination among drug
users. With serological evidence of HBV vaccination
considered the ‘‘gold standard,’’ the sensitivity and speci-
ficity of self-reported HBV vaccination was 48.5% and
79.0%, respectively in this study. However, the kappa
statistic was low (0.23), indicating that reliability of self-
report data is fair, at best, in this case . The lower
sensitivity that we observed may be due to a waning of
antibody response to a previously administered vaccine or
inaccurate self-reported vaccination history. These findings
suggest that self-reported HBV vaccination status may not
be valid and serological confirmation is warranted. Fur-
thermore, self-report of previous vaccination should not be
considered a contraindication for provision of vaccine. In
146J Community Health (2008) 33:139–148
the worst case scenario, the extra dose of vaccine would act
as a booster dose, and it would not affect those actively
infected. Vaccine may be given while additional antibody
testing results are obtained and vaccination/immunity sta-
tus is confirmed.
These results must be considered in the context of the
study’s limitations. The study population does not repre-
sent all IDUs and NIDUs in New York City, only those
who were approached in our recruitment scheme and were
willing to participate. Thus, the extent to which these
findings are generalizable to other situations is unclear.
However, in light of the lack of published data on corre-
lates of HBV vaccination among drug users, these data
provide valuable insight.
In summary, we found that the majority of the drug
users in this population were susceptible to HBV. These
results may provide guidance for interventions aimed at
improving HBV vaccine coverage among drug users across
all age groups and especially among the higher risk
younger group. Older drug users, many of whom are still
susceptible to HBV, continue to be missed by vaccination
programs. Drug users will be an important target popula-
tion when an HIV or HCV vaccine becomes available.
Understanding some of the correlates of HBV vaccination
can guide and inform strategies that will be designed for
HIV and HCV vaccination programs among this high risk
DA13146 and DA12801 from the National Institute on Drug Abuse.
The HBV vaccinations were provided by the New York City
Department of Health and Mental Hygiene. The authors would like to
acknowledge the contributions of Vincent Edwards and Sandra Del
Vecchio to the manuscript.
This study was partly funded by Grants
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