Texas Perinatal Hepatitis B Prevention ProgramTexas Perinatal Hepatitis B Prevention Program22ndnd Bi-Annual State Conference Bi-Annual State Conference

Designing an Effective Case Management ProgramDesigning an Effective Case Management Program

Lisa Jacques-Carroll, MSWLisa Jacques-Carroll, MSW

CDC, Immunization Services DivisionCDC, Immunization Services Division

May 11, 2010May 11, 2010

Learning ObjectivesLearning Objectives

Describe case management of HBsAg-Describe case management of HBsAg-positive and unknown pregnant womenpositive and unknown pregnant women

Describe case management of infants born Describe case management of infants born to women with positive or unknown HBsAg to women with positive or unknown HBsAg statusstatus

Describe case management of sexual and Describe case management of sexual and household contacts of pregnant women with household contacts of pregnant women with HBsAg positive or unknown statusHBsAg positive or unknown status

Define provider partnershipsDefine provider partnerships

Components of Case ManagementComponents of Case Management

Case initiationCase initiation Education of motherEducation of mother Treatment and management of infantTreatment and management of infant Management of household and sexual Management of household and sexual

contactscontacts Monitoring and evaluation of outcomesMonitoring and evaluation of outcomes

Background on Case ManagementBackground on Case Management

Benefits of Case ManagementBenefits of Case Management

Case managed infants are more likely to Case managed infants are more likely to receive post-exposure prophylaxis (PEP) receive post-exposure prophylaxis (PEP) at birth and to complete their vaccine at birth and to complete their vaccine series on timeseries on time

Household and sexual contacts are more Household and sexual contacts are more likely to be tested and vaccinatedlikely to be tested and vaccinated

Case Management in Perinatal Hepatitis B Virus (HBV) Prevention: State Examples

State State

InfantInfantReceivedReceived

case case management management No.(%)No.(%)

HBIG and HBIG and HepB at birthHepB at birth

No. (%)No. (%)

Complete Complete series series

by 8 moby 8 moNo. (%)No. (%)

AlabamaAlabama YesYes 982 (78)982 (78) 905 (92)905 (92) 828 (90)828 (90)

(1990-2002)(1990-2002) No No 318 (22)318 (22) 212 (67)212 (67) 189 (59)189 (59)

ConnecticutConnecticut YesYes 64 (52)64 (52) 64 (100)64 (100) 52 (90)52 (90)(1994-1995)(1994-1995) No 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

Case InitiationCase Initiation

Timing of IdentificationTiming of Identification

The management of an HBsAg-positive The management of an HBsAg-positive pregnant woman varies depending upon pregnant woman varies depending upon when she is identified:when she is identified: prenatallyprenatally at deliveryat delivery postnatallypostnatally

Prenatal Case InitiationPrenatal Case Initiation

1.1. Contact prenatal care provider to confirm:Contact prenatal care provider to confirm: HBsAg test resultsHBsAg test results date of testdate of test expected date of deliveryexpected date of delivery expected delivery hospitalexpected delivery hospital whether woman has been evaluated for her whether woman has been evaluated for her

HBV infection HBV infection

2.2. Notify the delivery hospitalNotify the delivery hospital

Prenatal Case Initiation - cont’dPrenatal Case Initiation - cont’d

3.3. Contact the woman to provide education Contact the woman to provide education and informationand information

4.4. Identify sex partners and household Identify sex partners and household contacts for testing, vaccination, and contacts for testing, vaccination, and follow-upfollow-up

Tips for working with the MotherTips for working with the Mother

Use mother’s first languageUse mother’s first language Use materials with visual aids/low reading Use materials with visual aids/low reading

level (if appropriate)level (if appropriate) Provide materials for review at homeProvide materials for review at home Reinforce messages with follow-up lettersReinforce messages with follow-up letters

immediately after first interviewimmediately after first interview just before due datejust before due date before each vaccination is duebefore each vaccination is due before post-vaccination testingbefore post-vaccination testing

Prior to DeliveryPrior to Delivery

Remind woman and delivery hospital of Remind woman and delivery hospital of importance of post-exposure prophylaxis importance of post-exposure prophylaxis for infant at birthfor infant at birth consider giving woman card to take to consider giving woman card to take to

hospital with instructions on care of infanthospital with instructions on care of infant consider sending hospitals monthly list of consider sending hospitals monthly list of

HBsAg-positive women expected to deliver HBsAg-positive women expected to deliver

After Expected Date of DeliveryAfter Expected Date of Delivery

Contact hospital to Contact hospital to determine:determine: date of deliverydate of delivery date/time of hepatitis date/time of hepatitis

B vaccine and HBIG B vaccine and HBIG updated contact updated contact

information for motherinformation for mother

HBsAg+ Woman Identified at Delivery HBsAg+ Woman Identified at Delivery or Post-natallyor Post-natally

Contact mother ASAP to provide Contact mother ASAP to provide information on hepatitis B virusinformation on hepatitis B virus

Ensure infant received hepatitis B Ensure infant received hepatitis B vaccine and HBIG vaccine and HBIG

Proceed with case management of infant Proceed with case management of infant Identify and manage sex partners and Identify and manage sex partners and

household contactshousehold contacts

Education of the MotherEducation of the Mother

Education of MotherEducation of Mother

Discuss with HBsAg+ pregnant woman:Discuss with HBsAg+ pregnant woman: What test results meanWhat test results mean Typical course of HBV infectionTypical course of HBV infection Seriousness of infection in newbornsSeriousness of infection in newborns How infant will be managedHow infant will be managed Perinatal concerns Perinatal concerns

(e.g., breastfeeding is safe) (e.g., breastfeeding is safe)

Education of Mother - cont’dEducation of Mother - cont’d

How she can take care of herselfHow she can take care of herself Importance of evaluation for HBV infectionImportance of evaluation for HBV infection Referral to physician for evaluationReferral to physician for evaluation How to prevent transmission to othersHow to prevent transmission to others Importance of identifying/vaccinating sex Importance of identifying/vaccinating sex

partners and household contactspartners and household contacts

Treatment and Management of Treatment and Management of InfantInfant

Management of Infant >2000g at Management of Infant >2000g at BirthBirth

Mother isMother is HBsAg positiveHBsAg positive hepatitis B vaccine within 12 hours of birthhepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birthHBIG within 12 hours of birth

Mother isMother is HBsAg status unknownHBsAg status unknown hepatitis B vaccine within 12 hours of birthhepatitis B vaccine within 12 hours of birth test mother for HBsAg ASAPtest mother for HBsAg ASAP if mother is HBsAg-positive if mother is HBsAg-positive give HBIG to give HBIG to

infant ASAP but no later than 7 days after infant ASAP but no later than 7 days after birthbirth

Management of Infant <2000g at Management of Infant <2000g at BirthBirth

Mother isMother is HBsAg positiveHBsAg positive hepatitis B vaccine within 12 hours of birthhepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birthHBIG within 12 hours of birth

Mother isMother is HBsAg status unknownHBsAg status unknown hepatitis B vaccine within 12 hours of birthhepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birthHBIG within 12 hours of birth test mother for HBsAg ASAPtest mother for HBsAg ASAP

After Birth to HBsAg+ WomanAfter Birth to HBsAg+ Woman

Remind pediatrician and parentsRemind pediatrician and parents need for infant to receive hepatitis B vaccine need for infant to receive hepatitis B vaccine

series on timeseries on time need for post-vaccination testing of HBsAg and need for post-vaccination testing of HBsAg and

anti-HBs at 9-18 months of age; after 3 doses anti-HBs at 9-18 months of age; after 3 doses of vaccineof vaccine

Verify dates hepatitis B vaccines were givenVerify dates hepatitis B vaccines were given Review post-vaccination test results with Review post-vaccination test results with

pediatricianpediatrician

Infant Post-Vaccination Test ResultsInfant Post-Vaccination Test Results

If HBsAg-negative & anti-HBs If HBsAg-negative & anti-HBs >>10 mIU/mL10 mIU/mL infant is protectedinfant is protected

If HBsAg-negative & anti-HBs <10 mIU/mLIf HBsAg-negative & anti-HBs <10 mIU/mL

revaccinate with 3-dose hep B seriesrevaccinate with 3-dose hep B series

retest 1–2 months after final doseretest 1–2 months after final dose If HBsAg-positiveIf HBsAg-positive

refer infant for medical evaluation/ refer infant for medical evaluation/ management of chronic HBV infectionmanagement of chronic HBV infection

report perinatal infection to CDC via report perinatal infection to CDC via NNDSS (NNDSS (National Notifiable Disease Surveillance SystemNational Notifiable Disease Surveillance System))

Household and Sexual ContactsHousehold and Sexual Contacts

Management of ContactsManagement of Contacts

Identify all household and sexual contacts Identify all household and sexual contacts of HBsAg-positive pregnant womanof HBsAg-positive pregnant woman Refer contacts for serologic testingRefer contacts for serologic testing Refer susceptible contacts for hepatitis B Refer susceptible contacts for hepatitis B

vaccinationvaccination Refer infected contacts for medical evaluation Refer infected contacts for medical evaluation

Program OutcomesProgram Outcomes

Completion of Follow-up for Infants of Completion of Follow-up for Infants of HBsAg-Positive Women, U.S.,1993-2008HBsAg-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%

0102030405060708090

100

TX Case Management Outcomes*, 2008TX Case Management Outcomes*, 2008

*For case managed infants. Texas data excludes Houston and San *For case managed infants. Texas data excludes Houston and San Antonio.Antonio.

HBIG & HepB at

birth

3 HepB by 8

Months

PVS Testing

Texas 94% 54% 35%

U.S. Average

95% 69% 53%

Methods to Increase OutcomesMethods to Increase Outcomes

Reminder and Recall SystemsReminder and Recall Systems

Notify before (reminder) and after (recall) Notify before (reminder) and after (recall) vaccines and tests are duevaccines and tests are due

Use for parents, pediatricians, and case Use for parents, pediatricians, and case workersworkers

How?How? postcards filled out by parent to be mailed by postcards filled out by parent to be mailed by

provider or health departmentprovider or health department computer-generated letterscomputer-generated letters phone callsphone calls prompts for case workers follow upprompts for case workers follow up

Data IntegrationData Integration

Some programs’ perinatal hepatitis B data Some programs’ perinatal hepatitis B data are integrated into other systems:are integrated into other systems: Immunization Information System (IIS)Immunization Information System (IIS)

infant hepatitis B vaccinations in this systeminfant hepatitis B vaccinations in this system Communicable disease reporting systemCommunicable disease reporting system

HBsAg-positive women reported to this systemHBsAg-positive women reported to this system

Increase PVS TestingIncrease PVS Testing

Utilize electronic systems such as state Utilize electronic systems such as state Medicaid database or immunization Medicaid database or immunization registry to find updated contact inforegistry to find updated contact info

Provide incentives to families to get infants Provide incentives to families to get infants tested ($10 gift cards)tested ($10 gift cards)

Keep cases open for longer/persistent Keep cases open for longer/persistent case managerscase managers

Working with Hospitals and ProvidersWorking with Hospitals and Providers

Ongoing need for education of delivery Ongoing need for education of delivery hospital staff, prenatal care providers, hospital staff, prenatal care providers, family practitioners and pediatricians on family practitioners and pediatricians on their roles in perinatal hepatitis B their roles in perinatal hepatitis B preventionprevention

Educating Prenatal Care ProvidersEducating Prenatal Care Providers

Remind prenatal care providers to screen Remind prenatal care providers to screen all pregnant women for HBsAg and report all pregnant women for HBsAg and report infected women to public healthinfected women to public health

Encourage providers to educate all Encourage providers to educate all pregnant women on the birth dose of pregnant women on the birth dose of hepatitis B vaccinehepatitis B vaccine

Educating Delivery HospitalsEducating Delivery Hospitals

Conduct policy reviews and medical Conduct policy reviews and medical record reviewsrecord reviews

Assure hospitals have policies:Assure hospitals have policies: Universal birth dose administrationUniversal birth dose administration Review/test all delivering women for Review/test all delivering women for

HBsAgHBsAg PEP for infants born to HBsAg-positive PEP for infants born to HBsAg-positive

and unknown womenand unknown women Report all cases to the health departmentReport all cases to the health department

Educating PediatriciansEducating Pediatricians

Encourage administration of birth Encourage administration of birth dose of HepB for all infantsdose of HepB for all infants

Educate on importance of timely Educate on importance of timely receipt of HepB series for infants receipt of HepB series for infants born to HBsAg-positive women and born to HBsAg-positive women and PVS testingPVS testing

Working with Community OrganizationsWorking with Community Organizations

Engage with community Engage with community organizations to help educate key organizations to help educate key players on their roles and players on their roles and responsibilities in perinatal responsibilities in perinatal hepatitis B preventionhepatitis B prevention

Provider PartnershipsProvider Partnerships

Develop relationships with local providersDevelop relationships with local providers Identify provider champions to help educate Identify provider champions to help educate

other providers and implement hospital other providers and implement hospital policiespolicies

Work with local ACOG and AAP chaptersWork with local ACOG and AAP chapters

Evaluate Your ProgressEvaluate Your Progress

Evaluating Case ManagementEvaluating Case Management

Proportion of infants receiving:Proportion of infants receiving: HepB vaccine & HBIG within 12 hours of birthHepB vaccine & HBIG within 12 hours of birth on-time completion of HepB vaccine serieson-time completion of HepB vaccine series post-vaccination testingpost-vaccination testing

Reasons for cases lost to follow-upReasons for cases lost to follow-up Proportion of screened and vaccinated Proportion of screened and vaccinated

household and sexual contactshousehold and sexual contacts

Evaluating Case Mgmt - cont’dEvaluating Case Mgmt - cont’d

Monitor case management outcomes:Monitor case management outcomes: compare program-wide rates to national ratescompare program-wide rates to national rates locally (county level)locally (county level) quarterly or monthlyquarterly or monthly over time (trends)over time (trends)