Date of Graduation


Document Type


Degree Type



School of Public Health



Committee Chair

Thomas Hulsey

Committee Member

Gordon Smith

Committee Member

Judith Feinberg

Committee Member

Brian Hendricks


Background and Objectives: For over a decade, West Virginia’s (WV) rate of acute hepatitis B has been the highest in the United States (US). In 2017, WV’s rate was 11.7 per 100,000 population, almost 12 times higher than the national rate. The increase in acute hepatitis B cases is largely due to substance misuse, including injection drug use (IDU). Hepatitis B is a vaccine preventable disease yet many at-risk adults remain unvaccinated and susceptible to infection. The objectives of our studies are to 1) describe yearly changes in acute hepatitis B incidence in WV and assess county-level impact of the WV Pilot Project using geospatial methods 2) assess hepatitis B vaccine dose completion by setting type in at-risk groups and 3) understand factors associated with hepatitis B virus (HBV) exposure in an emerging at-risk group of people who report using methamphetamine.

Methods: Study 1. County rates of acute hepatitis B and vaccine doses per 100,000 population were visualized biannually from 2011 to 2018. Local indicators of spatial autocorrelation were used to detect county-level clustering. Significant differences in the median rate of acute hepatitis B pre and post intervention in counties receiving vaccine were evaluated using Wilcoxon signed-rank test and bootstrapping estimates. A Bland-Altman graph visualized significant differences in county-level rates of acute hepatitis B before and after the WV Pilot Project compared to the statewide estimate. Study 2. Deidentified data were collected from local health departments (LHDs) receiving hepatitis B vaccine through the WV Pilot Project and for which participant forms were available. The odds of receiving all three or at least two doses of hepatitis B vaccine were calculated using bivariate, multivariable, and mixed-effects regression models. Study 3. National Health and Nutrition Examination Survey data were utilized to examine factors associated with HBV exposure among participants who reported ever using methamphetamine using bivariate and multivariable logistic regression.

Results: Study 1. Analyses identified significant geographic clustering of acute hepatitis B in southern WV across all four time-periods. Nine of the 18 (50%) counties receiving vaccine had significant declines in acute hepatitis B incidence compared to the statewide mean difference estimate. Study 2. Ten LHDs had data available representing 1,201 participants. In multivariable logistic regression, participants vaccinated at substance use treatment centers (aOR: 1.37; 95% CI: 1.01-1.86) and LHD family planning clinics (aOR: 3.74; 95% CI: 1.98-7.06) were more likely to receive the three-dose series compared to those vaccinated at LHD STD clinics. For the secondary outcome, participants vaccinated through substance use treatment centers (aOR: 1.79; 95% CI: 1.31-2.44), correctional facilities (aOR: 3.34; 95% CI: 2.09-5.34), and LHD family planning clinics (aOR: 3.97; 95% CI: 1.72-9.16) were significantly more likely to receive at least two doses. Study 3. Overall, 847 participants representing approximately 11,048,115 people, met the study inclusion criteria. In multivariable logistic regression, female sex (aOR 3.83, 95% CI 1.65 – 8.90), living below the poverty threshold (aOR 3.17, 95% CI 1.39 – 7.21), injection drug use (IDU) (aOR 4.89, 95% CI 1.95 – 12.26), active hepatitis C (HCV) infection (aOR 3.39, 95% CI 1.10 – 12.26), and identifying as men who have sex with men (aOR 28.21, 95% CI 5.19 – 153.38) were significantly associated with HBV exposure.

Conclusions: Despite the availability of a safe and effective hepatitis B vaccine, many individuals remain at risk of infection. Hepatitis B virus transmission continues in WV due in part to injection drug use and substance misuse. Ongoing efforts are needed to identify trends, guide testing and vaccination programs, and evaluate the effectiveness of those programs. Increased dissemination of hepatitis B vaccine through local health departments and existing harm reduction services can reduce the incidence of acute hepatitis B in states such as WV, which have been disproportionately affected by substance misuse.

Embargo Reason

Publication Pending

Included in

Epidemiology Commons