1. Session 4: Delivery Hospital as Safety Net Lisa Jacques-Carroll, MSW NCIRD, CDC

2. Learning Objectives  Explain how to work with delivery hospitals in the prevention of perinatal hepatitis B infection describe the importance of delivery hospitals in preventing perinatal hepatitis B virus (HBV) transmission describe the importance of delivery hospitals in preventing perinatal hepatitis B virus (HBV) transmission identify methods health departments can use to work with delivery hospitals identify methods health departments can use to work with delivery hospitals

3. Overview  Background  ACIP-recommended hospital policies  Education/working with hospitals  Assessing hospitals  Hepatitis B vaccination at birth

4. Rationale for Birth Dose Hepatitis B Vaccine Rationale for Birth Dose Hepatitis B Vaccine  Provides safety net to prevent perinatal HBV infections  Prevents 70%-95% of transmission to infants born to HBsAg-positive women  Protects children born to HBsAg-negative women from household transmission I got hepatitis B vaccine at birth

5. Importance of Delivery Hospitals  Delivery hospital is the safety net to prevent perinatal hepatitis B: last opportunity to determine pregnant woman’s HBsAg status last opportunity to determine pregnant woman’s HBsAg status immunoprophylaxis for infants born to HBsAg- positive/unknown-status women immunoprophylaxis for infants born to HBsAg- positive/unknown-status women hepatitis B birth dose to all newborns hepatitis B birth dose to all newborns

6. 2004 U.S. Birth Statistics*  95.3% of births to women known to have received prenatal care (at least one visit)  99.1% of births occurred in a hospital  24.1% of births were to foreign-born mothers *Source: NCHS 2004 Birth Certificate Data

7. HBsAg Prevalence Among Pregnant Women by Prenatal Screening Status Philadelphia, 1991 Prenatal Screening # of Women Tested# (%) HBsAg-positive Yes1,55512 (0.8) No20814 (6.7) Source: JAMA 1991;266:2852-5

8. CDC 2006 National Hepatitis B Hospital Survey- Preliminary Data  Medical record reviews of 191 delivery hospitals revealed: discrepancies in maternal HBsAg-status between maternal and infant records discrepancies in maternal HBsAg-status between maternal and infant records hep B vaccine NOT given within 12 hours to: hep B vaccine NOT given within 12 hours to: 17% infants born to HBsAg-positive women17% infants born to HBsAg-positive women 39% infants born to unknown status women39% infants born to unknown status women HBIG NOT given within 12 hours to: HBIG NOT given within 12 hours to: 33% infants born to HBsAg-positive women33% infants born to HBsAg-positive women 96% infants <2000g born to unknown-status women96% infants <2000g born to unknown-status women

9. ACIP-Recommended Hospital Policies: On Admission  On admission for delivery: review HBsAg status of woman review HBsAg status of woman include copy of original lab report in maternal and infant medical records include copy of original lab report in maternal and infant medical records perform HBsAg testing on women who: perform HBsAg testing on women who: do not have a documented resultdo not have a documented result are high risk*are high risk* had clinical hepatitis since previous testinghad clinical hepatitis since previous testing *Women with >1 sex partner in past 6 months, evaluated or treated for an STD, injection drug user, or have an HBsAg-positive sex partner

10. ACIP-Recommended Hospital Policies: After Delivery  After delivery: administer appropriate prophylaxis to infants* born to HBsAg-positive and unknown-status women administer appropriate prophylaxis to infants* born to HBsAg-positive and unknown-status women determine status of HBsAg-unknown women determine status of HBsAg-unknown women administer a dose of hepatitis B vaccine to all newborns administer a dose of hepatitis B vaccine to all newborns educate HBsAg-positive women about HBV educate HBsAg-positive women about HBV *See 2005 ACIP recommendations for details on infants <2000 grams

11. ACIP-Recommended Hospital Policies: At Discharge  At the time infant is discharged: provide infant’s immunization record to mother, and provide infant’s immunization record to mother, and remind her to take it to infant’s healthcare provider remind her to take it to infant’s healthcare provider

12. Educate Hospitals on Policies  Educate hospitals on policies and standing orders that should be in place to prevent perinatal hepatitis B transmission

13. Educate Hospitals on Reporting  Encourage hospitals to report all infants born to HBsAg-positive women consider a reporting form for hospitals to fax to health department consider a reporting form for hospitals to fax to health department include HBIG and hepatitis B documentationinclude HBIG and hepatitis B documentation educate hospital staff on documenting on universal reporting mechanisms (if applicable) educate hospital staff on documenting on universal reporting mechanisms (if applicable) maternal HBsAg statusmaternal HBsAg status infant HBIG and hepatitis B vaccinationinfant HBIG and hepatitis B vaccination

14. Case Management at Hospitals  Notify hospitals of HBsAg-positive women who plan to deliver at their facility some programs send monthly lists to hospitals some programs send monthly lists to hospitals  Remind hospitals to: follow-up on HBsAg-unknown status women follow-up on HBsAg-unknown status women treat infants born to HBsAg-positive and unknown-status women treat infants born to HBsAg-positive and unknown-status women report infants born to HBsAg-positive women report infants born to HBsAg-positive women

15. Hospital Quality Improvement  Carefully review care received by each infant born to an infected woman identify any gaps/errors that occurred at the hospital identify any gaps/errors that occurred at the hospital communicate these gaps/errors to appropriate hospital staff communicate these gaps/errors to appropriate hospital staff report perinatal infections to Joint Commission if errors occurred at delivery report perinatal infections to Joint Commission if errors occurred at delivery

16. Assessing Hospitals  Conduct hospital policy surveys and medical record reviews every five years at delivery hospitals to evaluate policies and practices on: maternal HBsAg screening maternal HBsAg screening post-exposure prophylaxis (PEP) to infants born to HBsAg-positive and unknown women post-exposure prophylaxis (PEP) to infants born to HBsAg-positive and unknown women universal hepatitis B birth dose vaccination universal hepatitis B birth dose vaccination

17. Assessing Hospitals- cont’d  Consider conducting medical record reviews targeting unknown status women to ensure infants receive appropriate care use vital statistics birth data for women with no prenatal care use vital statistics birth data for women with no prenatal care partner with other health department staff (HIV, STD) to review records partner with other health department staff (HIV, STD) to review records

18. NIS Birth Hepatitis B Vaccination Rates at 0-2 Days, United States

19. NIS Birth Hepatitis B Vaccination Coverage*, 2006 <30 30-49 Coverage (%) 50-69 > 70 * 0-2 days from birth DC NYC Philly Chicago HoustonSan Antonio

20. Hepatitis B Vaccination at Birth  Monitor state, city, and hospital-level hepatitis B birth dose rates (using National Immunization Survey (NIS), Immunization Information System (IIS), and/or medical record reviews)  Work with hospitals with low birth dose rates to identify barriers and increase coverage

21. Birth Vaccination- cont’d  Encourage hospitals to incorporate administration of the birth dose into routine infant care  Encourage delivery hospitals to enroll in the Vaccines for Children Program (VFC) to receive vaccine at no charge for VFC- eligible newborns  Projects with a universal birth dose vaccine supply have higher NIS birth dose rates

22. Conclusion  Delivery hospitals are the safety net to prevent hepatitis B virus transmission to newborns