Session 4:Session 4:Delivery Hospital as Safety NetDelivery Hospital as Safety Net

Lisa Jacques-Carroll, MSWLisa Jacques-Carroll, MSW

NCIRD, CDCNCIRD, CDC

Learning ObjectivesLearning Objectives

Explain how to work with delivery Explain how to work with delivery hospitals in the prevention of perinatal hospitals in the prevention of perinatal hepatitis B infection hepatitis B infection describe the importance of delivery hospitals describe the importance of delivery hospitals

in preventing perinatal hepatitis B virus in preventing perinatal hepatitis B virus (HBV) transmission(HBV) transmission

identify methods health departments can identify methods health departments can use to work with delivery hospitalsuse to work with delivery hospitals

OverviewOverview

BackgroundBackground ACIP-recommended hospital policiesACIP-recommended hospital policies Education/working with hospitalsEducation/working with hospitals Assessing hospitalsAssessing hospitals Hepatitis B vaccination at birthHepatitis B vaccination at birth

Rationale for Birth Dose Rationale for Birth Dose Hepatitis B VaccineHepatitis B Vaccine

Provides safety net to Provides safety net to prevent perinatal HBV prevent perinatal HBV infectionsinfections

Prevents 70%-95% of Prevents 70%-95% of transmission to infants born transmission to infants born to HBsAg-positive womento HBsAg-positive women

Protects children born to Protects children born to HBsAg-negative women HBsAg-negative women from household from household transmissiontransmission

I got hepatitis B vaccine at birth

Importance of Delivery HospitalsImportance of Delivery Hospitals

Delivery hospital is the safety net to Delivery hospital is the safety net to prevent perinatal hepatitis B:prevent perinatal hepatitis B: last opportunity to determine pregnant last opportunity to determine pregnant

woman’s HBsAg status woman’s HBsAg status immunoprophylaxis for infants born to HBsAg-immunoprophylaxis for infants born to HBsAg-

positive/unknown-status womenpositive/unknown-status women hepatitis B birth dose to hepatitis B birth dose to allall newborns newborns

2004 U.S. Birth Statistics*2004 U.S. Birth Statistics*

95.3% of births to 95.3% of births to women known to have women known to have received prenatal care received prenatal care (at least one visit)(at least one visit)

99.1% of births 99.1% of births occurred in a hospitaloccurred in a hospital

24.1% of births were to 24.1% of births were to foreign-born mothersforeign-born mothers

*Source: NCHS 2004 Birth Certificate Data

HBsAg Prevalence Among Pregnant

Women by Prenatal Screening StatusPhiladelphia, 1991

Prenatal

Screening

# of Women

Tested # (%)

HBsAg-positive

Yes 1,555 12 (0.8)

No 208 14 (6.7)

Source: JAMA 1991;266:2852-5

CDC 2006 National Hepatitis B CDC 2006 National Hepatitis B Hospital Survey- Hospital Survey- Preliminary DataPreliminary Data

Medical record reviews of 191 delivery Medical record reviews of 191 delivery hospitals revealed:hospitals revealed: discrepancies in maternal HBsAg-status discrepancies in maternal HBsAg-status

between maternal and infant recordsbetween maternal and infant records hep B vaccine NOT given within 12 hours to:hep B vaccine NOT given within 12 hours to:

• 17%17% infants born to HBsAg-positive women 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%33% infants born to HBsAg-positive women infants born to HBsAg-positive women • 96% infants <2000g born to unknown-status 96% infants <2000g born to unknown-status

womenwomen

ACIP-Recommended Hospital ACIP-Recommended Hospital Policies: On AdmissionPolicies: On Admission

On admission for delivery:On admission for delivery: review HBsAg status of womanreview HBsAg status of woman include copy of original lab report include copy of original lab report

in maternal and infant medical recordsin 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

ACIP-Recommended Hospital ACIP-Recommended Hospital Policies: After DeliveryPolicies: After Delivery

After delivery:After delivery: administer appropriate prophylaxis to infants* administer appropriate prophylaxis to infants*

born to HBsAg-positive and unknown-status born to HBsAg-positive and unknown-status womenwomen

determine status of HBsAg-unknown women determine status of HBsAg-unknown women administer a dose of hepatitis B vaccine to all administer a dose of hepatitis B vaccine to all

newbornsnewborns educate HBsAg-positive women about HBVeducate HBsAg-positive women about HBV

*See 2005 ACIP recommendations for details on infants <2000 grams

ACIP-Recommended Hospital ACIP-Recommended Hospital Policies: At DischargePolicies: At Discharge

At the time infant is At the time infant is discharged:discharged: provide infant’s provide infant’s

immunization record to immunization record to mother, andmother, and

remind her to take it to remind her to take it to infant’s healthcare infant’s healthcare providerprovider

Educate Hospitals on PoliciesEducate Hospitals on Policies

Educate hospitals on policies and standing Educate hospitals on policies and standing orders that should be in place to prevent orders that should be in place to prevent perinatal hepatitis B transmissionperinatal hepatitis B transmission

Educate Hospitals on ReportingEducate Hospitals on Reporting

Encourage hospitals to report all infants Encourage hospitals to report all infants born to HBsAg-positive womenborn to HBsAg-positive women consider a reporting form for hospitals to fax consider a reporting form for hospitals to fax

to health department to health department • include HBIG and hepatitis B documentationinclude HBIG and hepatitis B documentation

educate hospital staff on documenting on educate hospital staff on documenting on universal reporting mechanisms (if applicable)universal reporting mechanisms (if applicable)• maternal HBsAg statusmaternal HBsAg status• infant HBIG and hepatitis B vaccinationinfant HBIG and hepatitis B vaccination

Case Management at HospitalsCase Management at Hospitals

Notify hospitals of HBsAg-positive women Notify hospitals of HBsAg-positive women who plan to deliver at their facilitywho plan to deliver at their facility some programs send monthly lists to hospitalssome programs send monthly lists to hospitals

Remind hospitals to:Remind hospitals to: follow-up on HBsAg-unknown status women follow-up on HBsAg-unknown status women treat infants born to HBsAg-positive and treat infants born to HBsAg-positive and

unknown-status womenunknown-status women report infants born to HBsAg-positive womenreport infants born to HBsAg-positive women

Hospital Quality ImprovementHospital Quality Improvement

Carefully review care received by each Carefully review care received by each infant born to an infected womaninfant born to an infected woman identify any gaps/errors that occurred at the identify any gaps/errors that occurred at the

hospitalhospital communicate these gaps/errors to appropriate communicate these gaps/errors to appropriate

hospital staffhospital staff report perinatal infections to Joint Commission report perinatal infections to Joint Commission

if errors occurred at deliveryif errors occurred at delivery

Assessing HospitalsAssessing Hospitals

Conduct hospital policy surveys and Conduct hospital policy surveys and medical record reviews every five years at medical record reviews every five years at delivery hospitals to evaluate policies and delivery hospitals to evaluate policies and practices on:practices on: maternal HBsAg screeningmaternal HBsAg screening post-exposure prophylaxis (PEP) to infants post-exposure prophylaxis (PEP) to infants

born to HBsAg-positive and unknown womenborn to HBsAg-positive and unknown women universal hepatitis B birth dose vaccinationuniversal hepatitis B birth dose vaccination

Assessing Hospitals- cont’dAssessing Hospitals- cont’d

Consider conducting medical record Consider conducting medical record reviews targeting unknown status women reviews targeting unknown status women to ensure infants receive appropriate careto ensure infants receive appropriate care use vital statistics birth data for women with use vital statistics birth data for women with

no prenatal careno prenatal care partner with other health department staff partner with other health department staff

(HIV, STD) to review records(HIV, STD) to review records

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

50.6 53.7

40.6

28.3

41.546 47.9 48.5

0

20

40

60

80

100

1999 2000 2001 2002 2003 2004 2005 2006

Per

cen

tag

e

NIS Birth Hepatitis B Vaccination NIS Birth Hepatitis B Vaccination Coverage*, 2006Coverage*, 2006

<30

30-49

Coverage (%)

50-69

> 70* 0-2 days from birth

DC

NYC Philly

Chicago

Houston San Antonio

Hepatitis B Vaccination at BirthHepatitis B Vaccination at Birth

Monitor state, city, and hospital-level Monitor state, city, and hospital-level hepatitis B birth dose rates (using National hepatitis B birth dose rates (using National Immunization Survey (NIS), Immunization Immunization Survey (NIS), Immunization Information System (IIS), and/or medical Information System (IIS), and/or medical record reviews)record reviews)

Work with hospitals with low birth dose Work with hospitals with low birth dose rates to identify barriers and increase rates to identify barriers and increase coveragecoverage

Birth Vaccination- cont’dBirth Vaccination- cont’d

Encourage hospitals to incorporate Encourage hospitals to incorporate administration of the birth dose into routine administration of the birth dose into routine infant care infant care

Encourage delivery hospitals to enroll in the Encourage delivery hospitals to enroll in the Vaccines for Children Program (VFC) to Vaccines for Children Program (VFC) to receive vaccine at no charge for VFC-receive vaccine at no charge for VFC-eligible newbornseligible newborns

Projects with a universal birth dose vaccine Projects with a universal birth dose vaccine supply have higher NIS birth dose ratessupply have higher NIS birth dose rates

ConclusionConclusion

Delivery hospitals are the safety net to Delivery hospitals are the safety net to prevent hepatitis B virus transmission to prevent hepatitis B virus transmission to newbornsnewborns