Research article| Volume 36, ISSUE 6, P491-496, June 2009

Physician Practices Regarding Adult Hepatitis B Vaccination

A National Survey


      Less than 50% of adults with risk factors for hepatitis B infection have been vaccinated. Although primary care settings typically serve an important role in immunization delivery, little is known about adult hepatitis B vaccination practices in primary care, including the use of strategies such as standing orders to improve immunization rates. The objectives of this study were to assess, among family physicians and general internists, current approaches to assessing adult patients for hepatitis B risk factors, reported hepatitis B vaccination practices, and attitudes about standing orders for hepatitis B vaccination.


      From September to November 2006, a national sample of 433 family physicians and 420 general internists were surveyed. Results were analyzed in 2007 and 2008.


      Response rates were 65% for family physicians and 79% for general internists. Thirty-one percent of physicians reported assessing most or all adult patients for hepatitis B risk factors and vaccinating patients identified as high risk. Perceived barriers to hepatitis B vaccination included patients not disclosing high-risk behaviors, lack of adequate reimbursement for vaccination, and feeling too pressed for time to assess risk factors. Most surveyed physicians were very (47%) or somewhat (38%) supportive of using standing orders for hepatitis B vaccination in their practices. However, staff time constraints and patient unwillingness to disclose sensitive information to staff were perceived as barriers to using standing orders by a majority of respondents.


      In a national survey, less than one third of primary care physicians reported routinely assessing for and vaccinating adults with hepatitis B risk factors. This finding suggests that new strategies for adult hepatitis B vaccination in primary care settings are needed. Most physicians supported using standing orders for vaccination, but barriers were anticipated.
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        • CDC
        Surveillance for acute viral hepatitis—United States, 2006.
        MMWR Surveill Summ. 2008; 57: 1-24
        • CDC
        Disease burden from hepatitis A, B, and C in the United States.
        • CDC
        A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP), Part II: immunization of adults.
        MMWR Recomm Rep. 2006; 55: 1-33
        • Ganem D.
        • Prince A.M.
        Hepatitis B virus infection—natural history and clinical consequences.
        N Engl J Med. 2004; 350: 1118-1129
        • CDC
        A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP), Part I: immunization of infants, children, and adolescents.
        MMWR Recomm Rep. 2005; 54: 1-31
        • Alter M.J.
        Epidemiology and prevention of hepatitis B.
        Semin Liver Dis. 2003; 23: 39-46
        • Jain N.
        • Yusuf H.
        • Wortley P.M.
        • Euler G.L.
        • Walton S.
        • Stokley S.
        Factors associated with receiving hepatitis B vaccination among high-risk adults in the United States: an analysis of the National Health Interview Survey, 2000.
        Fam Med. 2004; 36: 480-486
        • CDC
        Hepatitis B vaccination coverage among adults—United States, 2004.
        MMWR Morb Mortal Wkly Rep. 2006; 55: 509-511
        • Nowalk M.P.
        • Zimmerman R.K.
        • Feghali J.
        Missed opportunities for adult immunization in diverse primary care office settings.
        Vaccine. 2004; 22: 3457-3463
        • CDC
        Use of standing orders programs to increase adult vaccination rates.
        MMWR Recomm Rep. 2000; 49: 15-16
        • Babbie E.R.
        The practice of social research.
        4th ed. Wadsworth Publishing Co, Belmont CA1986
        • Crane L.A.
        • Daley M.F.
        • Barrow J.
        • et al.
        Sentinel physician networks as a technique for rapid immunization policy surveys.
        Eval Health Prof. 2008; 31: 43-64
        • Nichol K.L.
        • Zimmerman R.K.
        Generalist and subspecialist physicians' knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey.
        Arch Intern Med. 2001; 161: 2702-2708
        • Davis M.M.
        • McMahon S.R.
        • Santoli J.M.
        • Schwartz B.
        • Clark S.J.
        A national survey of physician practices regarding influenza vaccine.
        J Gen Intern Med. 2002; 17: 670-676
        • Szilagyi P.G.
        • Shone L.P.
        • Barth R.
        • et al.
        Physician practices and attitudes regarding adult immunizations.
        Prev Med. 2005; 40: 152-161
        • Schuman H.
        • Presser S.
        Measuring a middle position.
        in: Questions and answers in attitude surveys Experiments on question form, wording, and context. Sage Publications, Inc, Thousand Oaks CA1996: 161-178
        • McMahon S.R.
        • Iwamoto M.
        • Massoudi M.S.
        • et al.
        Comparison of e-mail, fax, and postal surveys of pediatricians.
        Pediatrics. 2003; 111: e299-e303
        • Hosmer D.W.
        • Lemeshow S.
        Model-building strategies and methods for logistic regression.
        in: Applied logistic regression. John Wiley & Sons, Inc, New York1989: 82-134
        • Zhang J.
        • Yu K.F.
        What's the relative risk?.
        JAMA. 1998; 280: 1690-1691
        • McNutt L.A.
        • Wu C.
        • Xue X.
        • Hafner J.P.
        Estimating the relative risk in cohort studies and clinical trials of common outcomes.
        Am J Epidemiol. 2003; 157: 940-943
        • Wenrich M.D.
        • Curtis J.R.
        • Carline J.D.
        • Paauw D.S.
        • Ramsey P.G.
        HIV risk screening in the primary care setting: assessment of physicians skills.
        J Gen Intern Med. 1997; 12: 107-113
        • Liddicoat R.V.
        • Horton N.J.
        • Urban R.
        • Maier E.
        • Christiansen D.
        • Samet J.H.
        Assessing missed opportunities for HIV testing in medical settings.
        J Gen Intern Med. 2004; 19: 349-356
        • Jenkins T.C.
        • Gardner E.M.
        • Thrun M.W.
        • Cohn D.L.
        • Burman W.J.
        Risk-based human immunodeficiency virus (HIV) testing fails to detect the majority of HIV-infected persons in medical care settings.
        Sex Transm Dis. 2006; 33: 329-333
        • CDC
        Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.
        MMWR Recomm Rep. 2006; 55: 1-17
        • Eckrode C.
        • Church N.
        • English III, W.J.
        Implementation and evaluation of a nursing assessment/standing orders-based inpatient pneumococcal vaccination program.
        Am J Infect Control. 2007; 35: 508-515
        • Sokos D.R.
        • Skledar S.J.
        • Ervin K.A.
        • et al.
        Designing and implementing a hospital-based vaccine standing orders program.
        Am J Health Syst Pharm. 2007; 64: 1096-1102
        • Bardenheier B.H.
        • Shefer A.
        • McKibben L.
        • Roberts H.
        • Rhew D.
        • Bratzler D.
        Factors predictive of increased influenza and pneumococcal vaccination coverage in long-term care facilities: the CMS-CDC standing orders program Project.
        J Am Med Dir Assoc. 2005; 6: 291-299
        • Dexter P.R.
        • Perkins S.M.
        • Maharry K.S.
        • Jones K.
        • McDonald C.J.
        Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial.
        JAMA. 2004; 292: 2366-2371
        • Orenstein W.A.
        • Mootrey G.T.
        • Pazol K.
        • Hinman A.R.
        Financing immunization of adults in the United States.
        Clin Pharmacol Ther. 2007; 82: 764-768
        • Hinman A.R.
        • Orenstein W.A.
        Adult immunization: what can we learn from the childhood immunization program?.
        Clin Infect Dis. 2007; 44: 1532-1535
        • Tourangeau R.
        • Yan T.
        Sensitive questions in surveys.
        Psychol Bull. 2007; 133: 859-883