the period 1997–2005 and found that vaccination rates declined during the later years. Possible reasons for the decline include fiscal constraints and increasing rates of prior vaccination.

Several studies have reported that when STD clinics offered the hepatitis B vaccine, many patients at high risk for HBV infection opted to be vaccinated. A study of 194 STD clinic patients found that 62% had not previously been vaccinated for hepatitis B, and 50% of the 62% elected to receive the vaccination (Samoff et al., 2004). A national program to vaccinate adults at STD clinics for hepatitis B is likely to be cost saving to society (Miriti et al., 2008). In an anonymous HIV-testing program in Madison, WI, 86% of patients were considered to be at high risk for HBV infection; 51% of the 86% initiated hepatitis B vaccination, and 80% who initiated vaccination completed the vaccine series (Savage et al., 2000).

Foreign-born people from HBV-endemic countries who reside in the United States are at risk for HBV infection from sexual exposures. Continuing sexual transmission of HBV in these communities is likely. Thus, foreign-born adults may be at high risk for acquiring hepatitis B, and women may transmit the virus to their newborns. Foreign-born adults would benefit from laboratory testing to determine their infection status and subsequent hepatitis B vaccination of susceptible people.

Adults at Risk from Injection-Drug Use CDC estimates that injection-drug users (IDUs) account for 15% of acute HBV infections in the United States (Daniels et al., 2009). The incidence of HBV infection in susceptible IDUs ranges from 10 to 30 per 100 person-years (Des Jarlais et al., 2003; Hagan et al., 1999). Hepatitis B vaccine coverage rates in IDUs are low and estimated to be 3–20% (Altice et al., 2005; Kuo et al., 2004; Lum et al., 2008) (see Table 4-4). The highest reported vaccination rate in US IDUs was 22%, in new injectors studied in 2000–2002 (Lum et al., 2003). In a study conducted in San Francisco, only 13% of IDUs over 30 years old had ever been offered hepatitis B vaccination compared with 25% of younger injectors (Seal et al., 2000).

On-site hepatitis B vaccination achieves higher success rates in IDUs than referral to other locations (summarized in Table 4-4). In a multisite study of IDUs in five US cities, IDUs participating in a randomized clinical trial to reduce HIV and HCV transmission were offered hepatitis B vaccination under a variety of conditions. Vaccine uptake was highest when it was provided on site and during the initial study visit (Campbell et al., 2007). A New Haven mobile health van at a needle-exchange program found that 66% of those initially offered the hepatitis B vaccine completed all three doses (Altice et al., 2005). Des Jarlais et al. (2001) reported a 31% completion rate in Alaskan IDUs given an off-site referral compared with 83% in

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