that the vaccine series can be completed at other sites, such as drug-treatment centers and STD clinics.

Hepatitis B vaccination of inmates costs the correctional system $415 per HBV infection averted, but it provides additional postincarceration savings to society as a whole (Pisu et al., 2002).

Other At-Risk Adults

HIV-infected people. At a clinic that serves primarily HIV-infected patients in Jacksonville, FL, 45% of 1,576 HIV-infected patients were considered to be at risk for HBV infection (Bailey et al., 2008), and 30% of those at risk were not offered hepatitis B vaccine by their health-care providers. Routine hepatitis B vaccination at HIV clinics is highly cost-effective, with a cost of $4,400 per QALY gained (Kim et al., 2006). Similarly, hepatitis B vaccination at STD testing, counseling, and treatment sites has been demonstrated to be highly cost-effective (Miriti et al., 2008).

Institutionalized populations. Vellinga et al. (1999) reviewed the literature and reported that among institutionalized developmentally disabled people in the United States, the prevalence of anti-HBs antibody ranged from 36% to 63% in residents who had Down syndrome and from 48% to 69% in people who had other intellectual disabilities. HBsAg prevalence was very high—27–51% in people who had Down syndrome and 6–9% in people who had other intellectual disabilities—and this suggests that many residents of institutions are immunized by natural infection rather than by vaccination. The committee did not find data on rates of hepatitis B vaccination of institutionalized developmentally disabled people. Because they are at risk for hepatitis B, they would benefit from vaccination.

Occupational exposure to hepatitis B virus. Only 75% of health-care workers (HCWs) in the United States—a population at high risk for HBV infection—have received the three-dose vaccine series in 2002-2003 (Simard et al., 2007). The vaccination rate was highest in physicians and nurses (81%) and lowest among black HCWs (67.6%).

Identifying At-Risk Adults

As discussed above, recommendations regarding childhood hepatitis B vaccination are aimed at achieving universal coverage, and recommendations regarding adult vaccination focus on the identification of risk populations for targeted immunization efforts. The identification of at-risk adults has proved problematic (CDC, 2006), and current CDC recommendations have emphasized both site-based and individual-based risk assessment to

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