1. Texas Perinatal Hepatitis B Prevention Program 2 nd Bi-Annual State Conference Designing an Effective Case Management Program Lisa Jacques-Carroll, MSW CDC, Immunization Services Division May 11, 2010

2. Learning Objectives  Describe case management of HBsAg- positive and unknown pregnant women  Describe case management of infants born to women with positive or unknown HBsAg status  Describe case management of sexual and household contacts of pregnant women with HBsAg positive or unknown status  Define provider partnerships

3. Components of Case Management  Case initiation  Education of mother  Treatment and management of infant  Management of household and sexual contacts  Monitoring and evaluation of outcomes

4. Background on Case Management

5. Benefits of Case Management  Case managed infants are more likely to receive post-exposure prophylaxis (PEP) at birth and to complete their vaccine series on time  Household and sexual contacts are more likely to be tested and vaccinated

6. Case Management in Perinatal Hepatitis B Virus (HBV) Prevention: State Examples StateInfantReceivedcasemanagementNo.(%) HBIG and HepB at birth No. (%) Complete series by 8 mo No. (%) AlabamaYes 982 (78) 905 (92) 828 (90) (1990-2002)No 318 (22) 212 (67) 189 (59) ConnecticutYes 64 (52) 64 (52) 64 (100) 64 (100) 52 (90) 52 (90) (1994-1995)No 58 (48) 58 (48) 52 (90) 52 (90) 189 (48) 189 (48) Sources: Brian Wheeler, Alabama Dept of Public Health, 2004; MMWR 1996;45:584–7

7. Case Initiation

8. Timing of Identification  The management of an HBsAg-positive pregnant woman varies depending upon when she is identified: prenatally prenatally at delivery at delivery postnatally postnatally

9. Prenatal Case Initiation 1. Contact prenatal care provider to confirm: HBsAg test results HBsAg test results date of test date of test expected date of delivery expected date of delivery expected delivery hospital expected delivery hospital whether woman has been evaluated for her HBV infection whether woman has been evaluated for her HBV infection 2. Notify the delivery hospital

10. Prenatal Case Initiation - cont’d 3. Contact the woman to provide education and information 4. Identify sex partners and household contacts for testing, vaccination, and follow-up

11. Tips for working with the Mother  Use mother’s first language  Use materials with visual aids/low reading level (if appropriate)  Provide materials for review at home  Reinforce messages with follow-up letters immediately after first interview immediately after first interview just before due date just before due date before each vaccination is due before each vaccination is due before post-vaccination testing before post-vaccination testing

12. Prior to Delivery  Remind woman and delivery hospital of importance of post-exposure prophylaxis for infant at birth consider giving woman card to take to hospital with instructions on care of infant consider giving woman card to take to hospital with instructions on care of infant consider sending hospitals monthly list of HBsAg-positive women expected to deliver consider sending hospitals monthly list of HBsAg-positive women expected to deliver

13. After Expected Date of Delivery  Contact hospital to determine: date of delivery date of delivery date/time of hepatitis B vaccine and HBIG date/time of hepatitis B vaccine and HBIG updated contact information for mother updated contact information for mother

14. HBsAg+ Woman Identified at Delivery or Post-natally  Contact mother ASAP to provide information on hepatitis B virus  Ensure infant received hepatitis B vaccine and HBIG  Proceed with case management of infant  Identify and manage sex partners and household contacts

15. Education of the Mother

16. Education of Mother Discuss with HBsAg+ pregnant woman:  What test results mean  Typical course of HBV infection  Seriousness of infection in newborns  How infant will be managed  Perinatal concerns (e.g., breastfeeding is safe)

17. Education of Mother - cont’d  How she can take care of herself  Importance of evaluation for HBV infection  Referral to physician for evaluation  How to prevent transmission to others  Importance of identifying/vaccinating sex partners and household contacts

18. Treatment and Management of Infant

19. Management of Infant >2000g at Birth  Mother is HBsAg positive hepatitis B vaccine within 12 hours of birth hepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birth HBIG within 12 hours of birth  Mother is HBsAg status unknown hepatitis B vaccine within 12 hours of birth hepatitis B vaccine within 12 hours of birth test mother for HBsAg ASAP test mother for HBsAg ASAP if mother is HBsAg-positive  give HBIG to infant ASAP but no later than 7 days after birth if mother is HBsAg-positive  give HBIG to infant ASAP but no later than 7 days after birth

20. Management of Infant <2000g at Birth  Mother is HBsAg positive hepatitis B vaccine within 12 hours of birth hepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birth HBIG within 12 hours of birth  Mother is HBsAg status unknown hepatitis B vaccine within 12 hours of birth hepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birth HBIG within 12 hours of birth test mother for HBsAg ASAP test mother for HBsAg ASAP

21. After Birth to HBsAg+ Woman  Remind pediatrician and parents need for infant to receive hepatitis B vaccine series on time need for infant to receive hepatitis B vaccine series on time need for post-vaccination testing of HBsAg and anti-HBs at 9-18 months of age; after 3 doses of vaccine need for post-vaccination testing of HBsAg and anti-HBs at 9-18 months of age; after 3 doses of vaccine  Verify dates hepatitis B vaccines were given  Review post-vaccination test results with pediatrician

22. Infant Post-Vaccination Test Results  If HBsAg-negative & anti-HBs >10 mIU/mL  infant is protected  infant is protected  If HBsAg-negative & anti-HBs <10 mIU/mL  revaccinate with 3-dose hep B series  revaccinate with 3-dose hep B series  retest 1–2 months after final dose  retest 1–2 months after final dose  If HBsAg-positive  refer infant for medical evaluation/ management of chronic HBV infection  refer infant for medical evaluation/ management of chronic HBV infection  report perinatal infection to CDC via NNDSS ( National Notifiable Disease Surveillance System )  report perinatal infection to CDC via NNDSS ( National Notifiable Disease Surveillance System )

23. Household and Sexual Contacts

24. Management of Contacts  Identify all household and sexual contacts of HBsAg-positive pregnant woman Refer contacts for serologic testing Refer contacts for serologic testing Refer susceptible contacts for hepatitis B vaccination Refer susceptible contacts for hepatitis B vaccination Refer infected contacts for medical evaluation Refer infected contacts for medical evaluation

25. Program Outcomes

26. Completion of Follow-up for Infants of HBsAg-Positive Women, U.S.,1993-2008 Source: National Center for Immunization and Respiratory Diseases, CDC HBIG/vaccine at birth 3 doses by 8 months Post-vaccination testing 95% 69% 53%

27. TX Case Management Outcomes*, 2008 *For case managed infants. Texas data excludes Houston and San Antonio. HBIG & HepB at birth 3 HepB by 8 Months PVS Testing Texas 94%54%35% U.S. Average 95%69%53%

28. Methods to Increase Outcomes

29. Reminder and Recall Systems  Notify before (reminder) and after (recall) vaccines and tests are due  Use for parents, pediatricians, and case workers  How? postcards filled out by parent to be mailed by provider or health department postcards filled out by parent to be mailed by provider or health department computer-generated letters computer-generated letters phone calls phone calls prompts for case workers follow up prompts for case workers follow up

30. Data Integration  Some programs’ perinatal hepatitis B data are integrated into other systems: Immunization Information System (IIS) Immunization Information System (IIS)  infant hepatitis B vaccinations in this system Communicable disease reporting system Communicable disease reporting system  HBsAg-positive women reported to this system

31. Increase PVS Testing  Utilize electronic systems such as state Medicaid database or immunization registry to find updated contact info  Provide incentives to families to get infants tested ($10 gift cards)  Keep cases open for longer/persistent case managers

32. Working with Hospitals and Providers  Ongoing need for education of delivery hospital staff, prenatal care providers, family practitioners and pediatricians on their roles in perinatal hepatitis B prevention

33. Educating Prenatal Care Providers  Remind prenatal care providers to screen all pregnant women for HBsAg and report infected women to public health  Encourage providers to educate all pregnant women on the birth dose of hepatitis B vaccine

34. Educating Delivery Hospitals  Conduct policy reviews and medical record reviews  Assure hospitals have policies: Universal birth dose administration Universal birth dose administration Review/test all delivering women for HBsAg Review/test all delivering women for HBsAg PEP for infants born to HBsAg- positive and unknown women PEP for infants born to HBsAg- positive and unknown women Report all cases to the health department Report all cases to the health department

35. Educating Pediatricians  Encourage administration of birth dose of HepB for all infants  Educate on importance of timely receipt of HepB series for infants born to HBsAg-positive women and PVS testing

36. Working with Community Organizations  Engage with community organizations to help educate key players on their roles and responsibilities in perinatal hepatitis B prevention

37. Provider Partnerships  Develop relationships with local providers  Identify provider champions to help educate other providers and implement hospital policies  Work with local ACOG and AAP chapters

38. Evaluate Your Progress

39. Evaluating Case Management  Proportion of infants receiving: HepB vaccine & HBIG within 12 hours of birth HepB vaccine & HBIG within 12 hours of birth on-time completion of HepB vaccine series on-time completion of HepB vaccine series post-vaccination testing post-vaccination testing  Reasons for cases lost to follow-up  Proportion of screened and vaccinated household and sexual contacts

40. Evaluating Case Mgmt - cont’d  Monitor case management outcomes: compare program-wide rates to national rates compare program-wide rates to national rates locally (county level) locally (county level) quarterly or monthly quarterly or monthly over time (trends) over time (trends)