1. Case Identification for the Missouri Perinatal Hepatitis B Prevention Program Libby Landrum, RN, MSN Viral Hepatitis Prevention Manager Bureau HIV, STD, and Hepatitis Missouri Department of Health and Senior Services

2. Hepatitis B Reporting in Missouri Hepatitis B virus is a reportable condition in Missouri Missouri is a dual reporting state Mandated reporters: laboratories healthcare providers

3. Methods of Reporting Hepatitis B Laboratories report hepatitis B paper reports (mailed or faxed) electronic reports (electronic transfer) Healthcare providers report hepatitis B paper reports (mailed or faxed) communicable disease case report (CD-1) copy of original laboratory reports

4. Processing Hepatitis B Reports Positive hepatitis tests are submitted to: Department of Health and Senior Services or Local Public Health Agencies Health department staff: review and interpret the test results assign the appropriate hepatitis condition status according to the current CDC case definitions enter case information into the electronic state disease registry

5. Types of Case Identification Prospective Identification: identification of an HBsAg-positive pregnant woman Retrospective Identification: identification of an infant born to an HBsAg-positive pregnant woman

6. Case Identification in Missouri Missouri ~ 130 infants identified per year CDC Missouri estimates (156-258)

7. Review of HBsAg+ Women Positive hepatitis tests for females age 11 to 55 years earmarked for pregnancy status determination Entered using a specialized disease condition category in the state disease registry hepatitis B pregnancy condition pregnancy condition “suspect” status remains open (until pregnancy status is determined)

8. Determining Pregnancy Status Determination of pregnancy status assigned case manager contacts submitting healthcare provider documents pregnancy status on lab report Not pregnant pregnancy condition –“suspect status” changed to “no case” –appropriate hepatitis B condition entered (acute or chronic) –case investigated as usual –case closed

9. Opening a Case When pregnancy is verified hepatitis B pregnancy condition is changed from a “suspect” to “confirmed” in the state disease registry pregnant HBsAg-positive woman is enrolled into case management appropriate public health agency case manager notified appropriate case manager follows case to completion

10. Retrospective Case Identification Notifications of infants born to women with maternal risk factor of hepatitis B memorandum of agreement with the Bureau of Viral Records monthly report of births to mothers with hepatitis B as a maternal risk factor Transfer of infant born in another state Notification by healthcare provider or service provider familiar with our programs

11. Examples of Retrospective Identification Case investigation on a new HBsAg- positive pregnant woman finds an unreported infant born prior to current pregnancy Local public health agency identifies an unreported infant though a clinic visit or service provision Case investigator discovers retrospective infant during a case contact investigation

12. Relationships with Partners Case Managers and Program Staff Local public health agencies electronic notification fax case information Healthcare providers consultation technical assistance education interventions

13. Relationships with Partners (cont’d) Birthing Hospitals, Healthcare Providers, and Local Public Health Agencies birthing hospital site visits medical record reviews hepatitis B prevention education and recommendations regional trainings “One is Too Many” workshops hepatitis viral markers interpretation disease, prevention and treatment

14. Annual Educational Letters Physicians MD/DO Family Practice Pediatrics Obstetrics Nurse Practitioners Pediatrics Family Practice Obstetrics Midwives Local Public Health Communicable Disease Nurses

15. 2008 Updates State Case Manager/Quality Assurance Coordinator now contacts physicians Verifies pregnancy status Assigns appropriate pregnancy condition status in state disease registry expedites case follow-up decreases unreported cases increases prospective identification of infants at risk

16. Case Example A pregnant woman without prenatal care presented in emergency care to deliver The hospital has standing orders to test pregnant women of unknown HBsAg status upon admission for Labor and Delivery

17. Case Example (cont’d) The HBsAg test results were reported back within 10 hours of the infant’s delivery Woman tested HBsAg-positive The newborn nursery staff administered HBIG and the 1 st dose of monovalent hepatitis B vaccine within 12 hours of birth

18. Case Example (cont’d) Newborn nursery nurse reported case to infection control officer Infection control officer reported infant to Perinatal Hepatitis B Prevention Case Manager as a retrospective case

19. Case Outcome Follow-up case management initiated Infant received appropriate and timely immunoprophylaxis Post-vaccination serology testing indicated the infant was HBsAg- negative and anti-HBs >10mIU/mL (immune)

20. Critical Lessons Learned Important to establish relationships birthing hospital staff labor and delivery physicians and nurses newborn nursery nurses infection control nurses local obstetric providers local pediatricians local family practice providers

21. Partner Relationship Building Provide education and materials Respect other’s time and efforts Keep the goal of hepatitis B prevention a frequent topic of conversation

22. Questions?