Receipt Of Hepatitis Research Articles

Self-reported hepatitis B testing among noninstitutionalized adults in the United States before the implementation of universal screening, 2013-2017: A nationwide population-based study.

In 2023, the US Centers for Disease Control and Prevention recommended universal screening for hepatitis B virus (HBV); however, the proportion of US adults screened before implementing this recommendation is unknown. We analysed nationally representative data from the National Health Interview Survey (2013-2017) on self-reported HBV testing among noninstitutionalized US adults ≥18 years. We employed Poisson logistic regression to identify factors associated with self-reported testing, using a conceptual framework that included four overarching factors: sociodemographic characteristics, healthcare access, health-seeking behaviours and experiences, and access to internet-based health information. Among 149,628 survey respondents, the self-reported HBV testing rate was 27.2% (95% CI 26.2-28.7) and increased by 1.7% from 2013 to 2017 (p = .006). In adjusted analysis, health-seeking behaviours and experiences had the strongest associations of self-reported testing including a history of hepatitis (AOR 2.68, 95% CI 1.92-3.73), receipt of hepatitis B vaccination (AOR 5.11, 95% CI 4.61-5.68) and prior testing for hepatitis C (AOR 9.14, 95% CI 7.97-10.48) and HIV (AOR 2.69, 95% CI 2.44-2.97). Other factors associated with testing included being male (AOR 1.14, 95% CI 1.03-1.26), ages 30-44 years (AOR 1.37, 95% CI 1.17-1.61), 45-60 years (AOR 1.55, 95% CI 1.30-1.80) and ≥60 years (AOR 1.53, 95% CI 1.28-1.84), residence in the Western US region (AOR 1.23, 95% CI 1.06-1.43), and access to internet-based health information (AOR 1.32, 95% CI 1.18-1.47). Being Hispanic was associated with lower odds of testing (AOR 0.80, 95% CI 0.66-0.97). These findings may help guide optimal HBV screening in the universal testing era.

Receipt of hepatitis E vaccine and fetal loss in rural Bangladesh: further analysis of a double-blind, cluster-randomised, controlled trial

Vaccination constitutes an attractive control measure for hepatitis E virus (HEV), a major cause of maternal and perinatal mortality globally. Analysis of pregnant participants in an effectiveness trial of the HEV vaccine HEV239 showed possible HEV239-associated fetal losses. We aimed to conduct a detailed analysis of this safety signal. In a double-blind, cluster-randomised trial, 67 villages in Matlab, Bangladesh, were randomly allocated (1:1) to two vaccine groups, in which non-pregnant women aged 16-39 years received either HEV239 (HEV239 group) or Hepa-B (a hepatitis B vaccine; control group). We implemented weekly surveillance for pregnancy detection, and follow-up of pregnancies once every 2 weeks, using physician-confirmed diagnoses to evaluate fetal loss outcomes (miscarriage [spontaneous abortion], stillbirth, and elective termination). Data from a parallel system of reproductive health surveillance in Matlab were used to clarify study diagnoses when necessary. Miscarriage was assessed only among participants whose first positive pregnancy test and vaccination date (for whichever dose was closest to the date of last menstrual period [LMP]) were before 20 weeks' gestation. We defined the following analysis periods of interest: from 90 days before the LMP until the pregnancy outcome (the proximal period); from the LMP date until the pregnancy outcome (the pregnancy period); from 90 days before the LMP until the LMP date (90 days pre-LMP period); and from enrolment until 90 days before the LMP (the distal period). Both Poisson and Cox regression models were used to assess the associations between receipt of HEV239 and fetal loss outcomes. The trial was registered with ClinicalTrials.gov (NCT02759991). Among the 19 460 non-pregnant participants enrolled in the trial, 5011 were identified as having pregnancies within 2 years following vaccination and met the criteria for analysis (2407 in the HEV239 group and 2604 in the control group). Among participants vaccinated in the proximal period and evaluated for miscarriage, miscarriage occurred in 54 (8·9%) of 607 in the HEV239 group and 32 (4·5%) of 719 in the control group (adjusted relative risk [aRR] 2·0 [95% CI 1·3-3·1], p=0·0009). Similarly, the risk of miscarriages was increased in the HEV239 group versus the control group among participants inadvertently vaccinated during pregnancy (22 [10·5%] miscarriages among 209 participants in the HEV239 group vs 14 [5·3%] of 266 in the control group; aRR 2·1 [95% CI 1·1-4·1], p=0·036) and among those vaccinated within 90 days pre-LMP (32 [8·0%] of 398 vs 18 [4·0%] of 453; 1·9 [1·1-3·2], p=0·013). No increased risk of miscarriage was observed in those who received HEV239 in the distal period (93 [5·6%] of 1647 vs 80 [4·5%] of 1773; 1·3 [0·8-1·9], p=0·295). Stillbirth and elective termination showed no increased risk among women administered HEV239 versus those administered Hepa-B in any of the analysis periods. HEV239 given shortly before or during pregnancy was associated with an elevated risk of miscarriage. This association poses a possible safety concern for programmatic use of HEV239 in women of childbearing age. Research Council of Norway and Innovax.

Timing of hepatitis C treatment initiation and retention in office-based opioid treatment with buprenorphine: a retrospective cohort study

BackgroundThis study examined associations between receipt of hepatitis C (HCV) treatment and retention in office-based opioid treatment (OBOT) care.MethodsWe conducted a retrospective cohort study of HCV-infected patients who initiated OBOT treatment between December 2015 and March 2021 to characterize HCV treatment and assess associations with OBOT retention. HCV treatment was characterized as no treatment, early treatment (< 100 days since OBOT initiation) or late treatment (≥ 100 days). We evaluated associations between HCV treatment and cumulative days in OBOT. A secondary analysis using Cox Proportional Hazards regression was done to determine the rate of discharge over time when comparing those who did versus did not receive HCV treatment as a time-varying covariate. We also analyzed a subset of patients retained at least 100 days in OBOT care and evaluated whether HCV treatment during that period was associated with OBOT retention beyond 100 days.ResultsOf 191 HCV-infected OBOT patients, 30% initiated HCV treatment, of whom 31% received early treatment and 69% received late treatment. Median cumulative duration in OBOT was greater among those who received HCV treatment (any: 398 days, early: 284 days and late: 430 days) when compared to those who did not receive treatment (90 days). Compared to no HCV treatment, there were 83% (95% CI: 33–152%, P < 0.001), 95% (95% CI: 28%-197%, p = 0.002 and 77% (95% CI: 25–153%, p = 0.002) more cumulative days in OBOT for any, early and late HCV treatment, respectively. HCV treatment was associated with a lower relative hazard for discharge/drop-out, although results did not meet statistical significance (aHR = 0.59;95% CI: 0.34–1.00; p = 0.052). Among the subset of 84 patients retained in OBOT at least 100 days, 18 received HCV treatment during that period. Compared to those who did not receive treatment within the first 100 days, those who received treatment had 57% (95% CI: -3%-152%, p = 0.065) more subsequent days in OBOT.ConclusionsA minority of HCV-infected patients received HCV treatment after initiating OBOT treatment, but those who did had better retention. Further efforts are needed to facilitate rapid HCV treatment and evaluate whether early HCV treatment improves OBOT engagement.

Hepatitis A: Current view of an ancient disease

Hepatitis A: Current view of an ancient disease

607. Improving Health Maintenance Among Patients with HIV by Implementing a SmartPhrase and a Care Gap in the EPIC Electronic Medical Record

BackgroundMost deaths in HIV-infected patients receiving antiretroviral therapy are now related to conditions other than AIDS. HIV infection appears to increase the risk of many non-AIDS-related conditions, highlighting the importance of preventive care, however, recommended health maintenance items unique patients with HIV (PWH) are not always accomplished. We aimed to improve health maintenance by implementing a SmartPhrase and a Care Gap package in the EPIC Electronic Medical Record (EMR). MethodsWe developed a HIV health maintenance SmartPhrase in EPIC that included the last screening dates for syphilis, gonorrhea, chlamydia, hepatitis A, hepatitis B, hepatitis C, latent tuberculosis, hyperlipidemia, diabetes and human papilloma virus and the dates of receipt of hepatitis A vaccines, hepatitis B vaccines, pneumococcal conjugate vaccines, pneumococcal polysaccharide vaccines and influenza vaccines (Figure 1). Providers can select their plan for each health maintenance item based on these data and their plans are documented in the encounter notes. Providers were educated to use the SmartPhrase in each office visit. An HIV registry was built after choosing 509 HIV related medical conditions. The health maintenance topics were displayed in a “Care Gaps” summary using the data in the HIV registry (Figure 2). Completion rates for the health maintenance items were compared before and after implementation. The health maintenance package was implemented on 3/1/2020. Figure 1. SmartPhrase .IDNOTE description and note documentation Information relevant to health maintenance and providers' plan for each health maintenance are documented in the encounter notes.Figure 2. CareGaps© 2021 Epic Systems Corporation CD4 every 6 months is displayed as a part of the health maintenance in a “Care Gaps” summary using the data in the HIV registry, whether their HIV is well controlled or not.ResultsOf the 380 patients in the registry, 162 had office visits with the ID clinic from 1/1/20 to 6/5/20. Chart review of 100 patients who had office visits after implementation was performed and compared to the 62 patients prior to implementation (Table 1). The rates of hepatitis A vaccination (P= 0.001), hepatitis B vaccination (P= 0.05) and influenza vaccination (P=0.035) were increased significantly. Pneumonia vaccine administrations and anal pap smear performance compliance remained suboptimal. Providers reported that the time they spent searching for lab results and immunization records and documenting were shortened. The rates of hepatitis A vaccination (P= 0.001), hepatitis B vaccination (P= 0.05) and influenza vaccination (P=0.035) were increased significantly.ConclusionA health maintenance package consisting of a SmartPhrase and summary display in the EMR with provider education likely helps improve health maintenance in PWH. Disclosures All Authors: No reported disclosures

Using the power law model to predict the long-term persistence and duration of detectable hepatitis A antibody after receipt of hepatitis A vaccine (VAQTA™)

VAQTA™ (Hepatitis A Vaccine, inactivated [HAVi]; Merck & Co., Inc., Kenilworth, NJ, USA) is currently licensed for prevention of disease caused by hepatitis A virus in persons ≥12 months of age. This report summarizes statistical models developed to evaluate the long-term persistence and duration of detectable hepatitis A antibody (total antibody levels with no distinction on class) after receipt of HAVi in healthy children and adolescents (V251-023 and V251-035) and in healthy adults (V251-034). The statistical models presented, conducted separately for each of the three studies, are based on models that have been used in the literature to estimate the duration of antibody to protect against human papillomavirus (HPV) disease. In the absence of observed study data on hepatitis A antibody persistence for vaccine recipients over several decades, an extrapolation from a kinetic model of antibody decay was used to estimate the duration of detectable antibody. Extrapolation of observed antibody titers from postvaccination, Year 2.5–3.5, Year 5–6, and Year 10 in 165 children and adolescents who received HAVi at Day 0 and Week 24 in V251-023 suggests that detectable levels of antibody may persist after the second dose for many years. This model suggests that 25 to 50 years Postdose 1 in a two-dose series of HAVi, 99.4% of the study population will have detectable levels of hepatitis A antibody.

Persistence of antibody to Hepatitis A virus 20 years after receipt of Hepatitis A vaccine in Alaska

Hepatitis A vaccine is recommended for children ≥1year old to prevent hepatitis A virus (HAV) infection. However, the duration of vaccine-induced immunity is unknown. We evaluated a cohort of Alaska Native persons 20years after HAV vaccination. Children aged 3-6years had been previously randomized to receive three doses of HAV vaccine (360 ELISA units/dose) at: (i) 0,1,2months; (ii) 0,1,6months; and (iii) 0,1,12months. We measured anti-HAV antibody concentrations every 2-3years; described geometric mean concentrations (GMC) and the proportion with protective antibody (≥20 mIU mL-1 ) over time; and modelled the change in GMC using fractional polynomial regression. Of the 144 participants, after 20years 52 (36.1%) were available for the follow-up (17, 18, 17 children in Groups A, B and C, respectively). Overall, 46 (88.5%) of 52 available participants had anti-HAV antibody concentrations ≥20 mIU mL-1 , and overall GMC was 107 mIU mL-1 . Although GMC levels were lower in Group A (60; CI 34-104) than in Group B (110; CI 68-177) or Group C (184; CI 98-345) (B vs C: P=.168; A vs B/C: P=.011), there was no difference between groups after adjusting for peak antibody levels post-vaccination (P=.579). Models predicted geometric mean concentrations of 124 mIU mL-1 after 25years, and 106 mIU mL-1 after 30years. HAV vaccine provides protective antibody levels 20years after childhood vaccination. Lower antibody levels in Group A may be explained by a lower initial peak response. Our results suggest a booster vaccine dose is unnecessary for at least 25-30years.

HIV Infection Status as a Predictor of Hepatitis C Virus RNA Testing in Primary Care.

Receipt of hepatitis C virus (HCV) RNA testing following a positive HCV antibody (anti-HCV+) test result to establish current infection is a quality indicator for HCV-related care. This study examines HIV infection status as a predictor of HCV RNA test receipt after an anti-HCV+ result in the primary care setting. Electronic medical records of anti-HCV+ patients from a multisite retrospective study of patients aged ≥18 years who utilized one or more primary care outpatient services during 2005-2010 were analyzed in 2014. A multivariable logistic regression model examined the independent relationships between patient characteristics and receipt of HCV RNA testing. Among 1,115 anti-HCV+ patients, 133 (11.9%) were also HIV-positive. Of these, 77.4% (n=103) underwent HCV RNA testing to determine current infection status. By contrast, 66.7% (n=654/980) of anti-HCV+ patients who were HIV-negative received HCV RNA testing. Following multivariable adjustment, the odds of receiving HCV RNA testing were higher among anti-HCV+ patients who were also HIV-positive (AOR=1.9, 95% CI=1.2, 3.0), compared with their HIV-negative counterparts. Elevated alanine aminotransferase level was also associated with receipt of HCV RNA testing (AOR=1.9, 95% CI=1.4, 2.4). Black race was associated with decreased odds of receiving HCV RNA testing (AOR=0.7, 95% CI=0.5, 1.0). HIV infection status is independently associated with the likelihood of receiving HCV RNA testing following an anti-HCV+ result. One quarter of anti-HCV+ patients who were also HIV-positive and one third of their HIV-negative counterparts, respectively, did not receive testing to establish active HCV infection, which is imperative for appropriate care and treatment.

Costs of a Public Health Model to Increase Receipt of Hepatitis-Related Services for Persons With Mental Illness

This study examined the costs and impact on receipt of hepatitis and HIV testing and hepatitis immunization services of a public health intervention model that was designed for use by persons with serious mental illness and co-occurring substance use disorders. Between 2006 and 2008, a random sample of 202 nonelderly, predominantly African-American males with a psychotic or major depressive disorder and a co-occurring substance use disorder was recruited at four community mental health outpatient programs in a large metropolitan area. Participants were randomly assigned at each site to enhanced treatment as usual (N=97), including education about blood-borne diseases and referrals for testing and vaccinations, or to an experimental intervention (N=105) that provided on-site infectious disease education, screening of risk level, pretest counseling, testing for HIV and hepatitis B and C, vaccination for hepatitis A and B, and personalized risk-reduction counseling. The authors compared the two study groups to assess the average costs of improving hepatitis and HIV testing and hepatitis A and B vaccination in this population. The average cost per participant was $423 for the intervention and $24 for the comparison condition (t=52.7, df=201, p<.001). The costs per additional person tested was $706 for hepatitis C, $776 for hepatitis B, and $3,630 for HIV, and the cost per additional person vaccinated for hepatitis was $561. Delivery of hepatitis and HIV public health services to persons with serious mental illness in outpatient mental health settings can be as cost-effective as similar interventions for other at-risk populations.

The Association of Hepatitis B Vaccine Supply Policy with Timing of Receipt of the First Dose of Hepatitis B Vaccination

An estimated 800,000 - 1.4 million persons in the US have chronic hepatitis B virus (HBV) infection. The risk for chronic infection is greatest among young children; approximately 90% of infants will remain chronically infected with HBV. Approximately 25% of those who become chronically infected during childhood die prematurely from cirrhosis or liver cancer. Hepatitis B vaccination is the most effective measure to prevent HBV infection and its consequences. In 2006, 29 US states had Hepatitis B Vaccine Supply (HBVS) policy which either supplies hepatitis B vaccine at no cost to all providers for all children or provides hepatitis B vaccine to delivery hospitals-only free of charge for all infants; other 21 US states and the District of Columbia did not have. 17,636 infants born in 2006 obtained from 2007-2009 National Immunization Survey (NIS) were analyzed with survival analysis procedures of Kaplan-Meier estimate and Cox proportional hazards model for complex sample survey to evaluate the association between state HBVS policy and the timing of infant age in days to receipt of hepatitis B vaccination. State HBVS policy is associated with infant age in days from birth to receipt of the first dose of hepatitis B vaccine (P < 0.01), and to completion of the 3-dose hepatitis B vaccine series (P < 0.01). Receipt of the first dose of hepatitis B vaccine occurred 31% earlier among infants residing in states with HBVS policy than among infants residing in states without (adjusted hazards ratio 1.31, 95%CI (1.23, 1.39)). Completion of the 3-dose hepatitis B vaccine series were 12% sooner among infants living in states with HBVS policy than among infants living in states without (adjusted hazards ratio 1.12, 95%CI (1.06, 1.18)). State HBVS policy may help overcome barriers to timely delivery of hepatitis B vaccines to infants.

The Impact of State Policies on Vaccine Coverage by Age 13 in an Insured Population

Purpose To determine the impact of state policies on vaccine coverage among adolescents with managed care insurance. Methods We used the 2003 Health Plan Employer Data and Information Set to determine state-specific hepatitis B and varicella vaccine coverage among children with managed care insurance who turned 13 years in 2002. Our outcomes of interest were receipt of hepatitis B and varicella vaccines by age 13. Utilizing weighted least-squares methods, multiple linear regression models were developed to evaluate the relationship between hepatitis B and varicella vaccine coverage and state policies, while controlling for state sociodemographic variables. Results Across 28 states, adolescent hepatitis B vaccine coverage ranged from 35.3% to 80.5% (mean = 55.3%) and varicella vaccine coverage ranged from 22.9% to 7.6% (mean = 42.3%). In separate multiple regression models, after adjusting for potentially confounding sociodemographic variables, middle school mandates were significantly associated with hepatitis B vaccine coverage ( p = .002) and varicella vaccine coverage ( p = .024). Other policies, including universal purchase of vaccines and availability of philosophic exemptions, were not associated with vaccine coverage in this insured population. Conclusions In this population of insured adolescents, middle school vaccine mandates were the only state policy associated with improved hepatitis B and varicella vaccine coverage. Mandates are an effective method for promoting adolescent immunization.

Hepatitis B vaccine and risk of autoimmune thyroid disease: a Vaccine Safety Datalink study

Hepatitis B vaccine has been postulated as a possible cause of autoimmune disorders, including autoimmune thyroid diseases (ATD). Cases of Graves' disease and Hashimoto's thyroiditis, following hepatitis B vaccine have been reported to the Vaccine Adverse Events Reporting System (VAERS). To test the hypothesis that hepatitis B vaccine increases the risk of ATD, we conducted a case-control study, within the Vaccine Safety Datalink project. We identified potential cases of Graves' disease and Hashimoto's thyroiditis, among persons aged 18-69 years from administrative data recorded by three health maintenance organizations (HMOs) and verified cases by medical record review. Controls were frequency-matched to cases by birth year, sex, and study site. Vaccine information was collected from administrative records, chart review, and telephone interviews with study subjects. We enrolled 355 Graves' disease cases, 418 Hashimoto's thyroiditis cases, and 1102 controls. We assessed the association between ever-receipt of hepatitis B vaccine, as well as receipt of hepatitis B vaccine less than 1 year, 1-5 years and at least 5 years prior to the index date, and the risk of ATD. Ever-receipt of hepatitis B vaccine was not associated with risk of Graves' disease (odds ratio (OR), 0.90; 95% confidence interval (CI), 0.62-1.32) or Hashimoto's thyroiditis (OR, 1.23; 95%CI, 0.87-1.73). There was also no association between the time interval since receipt of hepatitis B vaccination and either outcome. We did not observe an increased risk of Graves' disease or Hashimoto's thyroiditis, following receipt of hepatitis B vaccine.

Impact of thimerosal-related changes in hepatitis B vaccine birth-dose recommendations on childhood vaccination coverage.

In July 1999, the longstanding preference to begin hepatitis B vaccination of all US infants at birth was temporarily suspended because of concerns about exposure to mercury contained in the vaccine preservative thimerosal. The suspension was lifted in September 1999 when preservative-free hepatitis B vaccine became available. To determine the effects of changes in recommendations regarding administration of a hepatitis B birth dose on vaccination coverage. Cohort analysis of vaccination status of 41,589 US children born before, during, and after the recommendation to suspend the birth dose. Association between birth cohort and age at receipt of hepatitis B vaccine dose 1, and receipt by 19 months of age of all recommended vaccines. The proportion of US infants who received dose 1 of hepatitis B vaccine at birth declined from 47% among those born 7 to 12 months before the suspension to 11% among those born during the suspension. Birth-dose coverage remained significantly lower in the year after the suspension was lifted (23% in the first 6 months and 33% in months 7-12). Coverage with 3 doses of hepatitis B vaccine by 19 months of age declined from 88% among those born 7 to 12 months before the suspension to 81% among those born during the suspension and 85% among those born in the 6 months after the suspension, but returned to baseline levels for those born 7 to 12 months after the suspension was lifted. These reductions represent 750,000 fewer newborns vaccinated during 2000 compared with 1998, and an excess 182,000 children undervaccinated for hepatitis B at 19 months of age compared with 1998 coverage levels. Coverage with other recommended vaccinations did not decline over this time. Reductions in hepatitis B vaccine birth-dose coverage persisted after recommendations were made to resume previous newborn vaccination practices. Although the recommendation to complete the series by 19 months of age was never changed, infants born between July and December 1999 were less likely to have completed the series by 19 months, compared with infants born during the previous year. The lack of impact on other vaccinations suggests that public confidence in immunization remained strong.

Protective effect of hepatitis B vaccine in chronic hemodialysis patients.

Hepatitis B virus (HBV) infection is a well-recognized risk in chronic hemodialysis patients. Although the risk has declined dramatically since the 1970s, outbreaks of HBV infection among these patients continue to occur. The Centers for Disease Control and Prevention (CDC) has recommended hepatitis B vaccination of hemodialysis patients since 1982; however, by 1996, only 36% of the approximately 200,000 US chronic hemodialysis patients had received the vaccine, perhaps in part because of doubts among dialysis personnel of its efficacy. We performed a case-control study to determine whether receipt of hepatitis B vaccine was associated with a decreased risk of acquiring HBV infection. We determined the vaccination status of all chronic hemodialysis patients at 98 US hemodialysis centers that reported patients with acute HBV infection on a nationwide mailed survey in 1995. A total of 111 hepatitis B surface antigen (HBsAg) positive case patients were compared with 12,500 control patients. Case patients were significantly less likely than control patients to have received hepatitis B vaccine (10.8% v 23.6%; odds ratio, 0.39; 95% confidence interval, 0.22-0.72). After stratifying by dialysis center to control for differing community and dialysis center risks of HBV infection, we found that the risk for HBV infection was 70% lower in vaccinated patients (adjusted odds ratio, 0.30; 95% confidence interval, 0.18-0.50). These results suggest that hepatitis B vaccine has a significant protective effect against acquiring HBV infection in chronic hemodialysis patients, and efforts should be expanded to increase the use of hepatitis B vaccine in this patient population.

A population-based survey of immunization coverage in children aged 2 years and younger in New South Wales.

To provide a population-based baseline of immunization rates in children aged 2 years and younger in New South Wales (NSW) in 1992, permitting more accurate evaluation of the efficacy of current programmes. A cross-sectional population-based survey of 622 households from areas resident to over 73% of all children aged 4 years and younger in NSW. Of the 322 households with children aged 3-24 months, 212 (66%; confidence interval (CI): 57-75%) were up-to-date with the recommended immunization schedule, 68 (21%; CI: 15-27%) had not commenced any immunization, and 42 (13%; CI: 9-17%) were partially immunised. Ability to read English (odds ratio (OR): 5.43; CI: 2.37-12.44) and receipt of hepatitis B immunization (OR; 2.54; CI: 1.27-5.07%) were highly associated with up-to-date immunization; whilst a history of any illnesses, frequent doctor visits in the past 12 months (OR: 0.47; CI: 0.27-0.85%) and older age (16-24 months) (OR: 0.26; CI: 0.12-0.50%) were less likely to be associated with up-to-date immunization. In 1992 NSW had low levels of up-to-date immunization. Significantly, one-fifth of NSW families with children aged 3-24 months did not have a record of any immunizations. This could not be explained by delay in commencing immunization. Poor competency in reading English was strongly associated with failure to immunise, suggesting that there had been inadequate targeting of immunization campaigns in non-English-speaking communities.