A targeted and sustainable service

1. A targeted and sustainable service? Tom Fowler- Public Health Registrar Lisa Vallente-Osborne- Immunisation Programme Manager Immunisation Branch Wellington House Who we are…Who we are…

2. Hepatitis B as a public health risk. Hepatitis B infection is a risk to public health. Mortality rates from liver disease are rising in the UK. Untreated, persistent HBV infection may lead to premature death either due to cirrhosis or hepatocellular carcinoma in a large proportion of individuals’ infected .4 25% liver disease due to Hepatitis infection 21% of all new persistent HepB infections due to vertical transmission 25% liver disease due to Hepatitis infection 21% of all new persistent HepB infections due to vertical transmission

3. Hepatitis B as a targeted immunisation programme. Hepatitis B services are historically commissioned Vaccines are given to babies identified at risk, following universal antenatal screening. An effective and integrated pregnancy screening and neonatal vaccination service is fundamental to minimise hepatitis B transmission is therefore, to the protection of babies.

4. Timely vaccinations 10% of infected women are highly infectious, e.g. those HBeAg seropositive Between 70% and 90% of highly infectious women pass infection to their baby Around 90% of infected babies will develop persistent HBV infection Timely immunisation prevent 90% of persistent HBV infection in these cases. Timely administration of HBV provides best protection for baby and were vaccines are delayed- the course should continue, but it is more likely that the child may become infected. Serology testing at 12 months becomes even more important.5 there is a 10% likelihood that it will be transferred to the baby if the women is infected but not highly infectious.7 there is a 10% likelihood that it will be transferred to the baby if the women is infected but not highly infectious.7

5. Gaps in currently commissioned historic services Reports to DH suggest: 1,6 there are gaps in service delivery services not well organised services not well accessed services are confusing for patients and professionals data poor A London audit found 95% of ‘at risk’ infants were given the first vaccination but only 49% completed their schedule Reports from: anecdotal feedback from VINST and vaccine coordinators, coordinator days and London study. Seen also from DH data returns Reports from: anecdotal feedback from VINST and vaccine coordinators, coordinator days and London study. Seen also from DH data returns

6. This slide illustrates the outline for a classic Hep B screening and pathway delivery. The variety of stages are delivered by locally commissioned providers. Due to their locality; these vary across the country. (Fourth Vaccine and Serology testing (we will explain verbally why important, have in notes for printout)) This slide illustrates the outline for a classic Hep B screening and pathway delivery. The variety of stages are delivered by locally commissioned providers. Due to their locality; these vary across the country. (Fourth Vaccine and Serology testing (we will explain verbally why important, have in notes for printout))

7. Department of Health guidance in development Aimed at commissioners and providers Raises awareness of Hep B care pathway Identifies common barriers and gives guidance as to how to address these Gives advice on areas that may need local audit/assurance provide guidance and support for providers and commissioners of service provide guidance and support for providers and commissioners of service

8. Pathway overview- outlined in best practice document Highlight pathway, Awareness of fullness of pathway Stage 1 & 2: What happens in your area if a woman misses her appointment? Or refuses test or if midwife is unable to obtain blood sample (poor veins etc) Stage 2 & 3: what happens if the woman is not given the appropriate information, and so fails to understand the importance of appointments set up for her? What if the results are lost, missed and go to the GP instead of Midwife and are therefore not acted upon? Highlight pathway, Awareness of fullness of pathway Stage 1 & 2: What happens in your area if a woman misses her appointment? Or refuses test or if midwife is unable to obtain blood sample (poor veins etc) Stage 2 & 3: what happens if the woman is not given the appropriate information, and so fails to understand the importance of appointments set up for her? What if the results are lost, missed and go to the GP instead of Midwife and are therefore not acted upon?

9. Service barriers Systems to ensure first vaccination/ hepatitis B immunoglobulin is given Non consent to HBIG and vaccination Availability and administration of vaccinations Timely ordering of HBV vaccine and HBIG Lack of communication between specialist services and maternity services/Delay in referral to specialist service. Lack of communication with the delivery team Home delivery. Pregnant woman screens negative but there is a known positive close family contact. Existing maternal diagnosis of HBV infection Lack of communication with the immunisation coordinator and passing of information to COVER regarding the administration of the initial vaccine dose/HBIG StageStage

10. Service Barriers Systems to ensure subsequent vaccinations are given and that the child is tested for HBV infection at 12 months of age Failure to pass all relevant information in a timely manner from maternity services to health professionals completing schedule Immunisation schedule may not be completed where a baby remains in hospital. Non-standardised care across a locality Movement (removal) in/out of area Mother/baby does not attend the vaccine appointment Positive serology result/ incomplete serology testing / /immunity not achieved at 12 months. Incomplete serology testing due to difficulty in obtaining sample Failsafe in place Lack of communication with the immunisation co-ordinator and passing of information to COVER regarding the administration of the subsequent vaccine dose. Need for pre school booster overlooked

11. [D.N. Tom prob need to narrow these down to one or two slides.. Or even just one as an example bu then I’ll read other questions within the checklist- what do you think?] [D.N. Tom prob need to narrow these down to one or two slides.. Or even just one as an example bu then I’ll read other questions within the checklist- what do you think?]

12. And finally… Your Hepatitis B service Consider: if you are aware of all the components of your HBV service how robust is your service- fit for practice? how sustainable is it- especially considering the evolutionary changes over next few years? Best Practice document launch spring 2011 and if not- how can you gain that information/insight? and if not- how can you gain that information/insight?

13. Thank you.

14. References 1. DH (2011) Hepatitis B antenatal screening and newborn immunisation programme. Best Practice Guidance. [to be launched Feb 2011] 2.Reducing differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years. NICE public health guidance 2009. September http://guidance.nice.org.uk/PH21/Guidance/pdf/English 3.Infectious disease in pregnancy screening programme standards. UK National Screening Committee September 2010 http://infectiousdiseases.screening.nhs.uk/standards 4. Case-finding for hepatitis B and C virus infection in minority ethnic populations in the UK. Advisory Group on Hepatitis, August 2009 www.library.nhs.uk/SpecialistLibrarySearch/ Download.aspx?resID=383365 5. Green book: Immunisation against infectious disease. Department of Health 2006, http://www.dh.gov.uk/en/Publichealth/Healthprotection/ Immunisation/ Greenbook/DH4097254 6. Factors associated with incomplete vaccination of babies at risk of perinatal hepatitis B transmission: A London study in 2006. Giraudon I; Permalloo N; Nixon G; Charlett A; Cohuet S; Mandal S; Ramsay M; Patel B C and Maguire H. Vaccine 27 (2009) 2016-22.

15. In a schedule where a child is automatically called and attends appointments, there are potentially 16 stages where the child can be missed.In a schedule where a child is automatically called and attends appointments, there are potentially 16 stages where the child can be missed.