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Universal Birth Dose Hepatitis B: A Safety Net. Pat Fineis Michigan Department of Community Health. Overview. History of Michigan’s Universal Hepatitis B Vaccination Program Case example and responses to tragedy

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universal birth dose hepatitis b a safety net

Universal Birth Dose Hepatitis B: A Safety Net

Pat Fineis

Michigan Department of Community Health

overview
Overview
  • History of Michigan’s Universal Hepatitis B Vaccination Program
  • Case example and responses to tragedy
  • Process of adding hepatitis B (hep B) administration information to birth certificate and immunization registry
  • Evaluation tools and methods to increase hep B birth dose coverage levels
  • Barriers to implement birth dose
  • Hospital enrollment process
michigan s history
Michigan’s History
  • 1991 Universal Hepatitis B Vaccination Program began
    • Goal: offer hep B vaccine to all birthing hospitals for all infants
      • Michigan’s birth cohort
        • 132,000 (1991)
        • 128,000 (2007)
      • Visited and provided education to all birthing hospitals (102)
hepatitis b birth dose is postponed
Hepatitis B Birth Dose is Postponed
  • July – September 1999
    • Thimerosal statement released
    • Recommendation:
      • Postpone birth dose until 2 - 6 months of age if infant born to hepatitis B surface antigen (HBsAg)-negative woman
      • Give birth dose to infants born to HBsAg-positive and unknown HBsAg status women
case example
Case Example
  • Mother
    • 15 y.o. HBsAg-positive Laotian female
    • 10 prenatal visits
    • Lab and prenatal care provider (PCP) did not report HBsAg-positive result to local health department (LHD)
    • PCP reported HBsAg result as negative on prenatal record sent to delivery hospital
  • Infant
    • Healthy baby girl born (38 wks gestation)
    • Mom’s HBsAg status also noted as HBsAg-negative in baby’s chart
    • Due to recommendation to delay birth dose, no hep B vaccine was given
case example cont d
Case Example (cont’d)
  • 2 months of age
    • 1st dose of hep B vaccine
  • 3 months of age
    • Ill with fever, diarrhea, jaundice
  • 5 days after onset of symptoms
    • Diagnosed with HBV infection and acute liver failure
  • 8 days after becoming ill
    • Infant dies
response to situation
Response to Situation
  • Presented case study in newsletters and conferences
  • Visited 102 birthing hospitals
    • Provided new CDC recommendations
    • Reinforced state law
    • Recommended original lab report with prenatal record to birthing hospital
method to assess efforts
Method to Assess Efforts
  • Conducted hospital surveys
    • 1999
      • 82 of 102 (80%) had written policies and standing orders to give hep B birth dose
    • 2001
      • 92 of 102 (90%) had written polices and standing orders
  • Identified need for an assessment tool to measure hep B birth dose
adding hepatitis b to electronic birth certificate ebc 1999 2000
Adding Hepatitis B to Electronic Birth Certificate (EBC), 1999-2000
  • Meetings with records manager and data entry staff
  • Goal:
    • Documentation of hep B vaccine dose on EBC
    • Box created to include hep B vaccine administration
        • Yes or No field
        • Date vaccine given (month/day/year)
adding hepatitis b birth dose to immunization registry 2000 2001
Adding Hepatitis B Birth Dose to Immunization Registry, 2000-2001
  • Identified need to capture hep B birth dose through the immunization registry
  • Meetings with immunization registry coordinator and technology staff - Michigan Care Improvement Registry (MCIR)
  • Goal:
    • Create a process to obtain the birth dose data
    • Develop process to download EBC birth dose data into MCIR
monitoring hep b birth dose 2002
Monitoring Hep B Birth Dose, 2002
  • Began monitoring the birth dose coverage levels
  • Developed reports based on the information entered into Michigan Care Improvement Registry (MCIR)
    • County
    • Birthing hospital
      • Number of births
      • Number of doses given within 4 days of life
      • Percentages of births/number of doses
  • Discovered only 72% of Michigan’s babies were receiving hep B birth dose
issues and barriers
Issues and Barriers
  • Lag time of 2 – 3 weeks to get birth dose data into MCIR
  • Downloading problems
    • Electronic systems not compatible
    • Billing data conflicts
    • Some hospitals batching data
  • Documentation problems
    • EBC didn’t include hep B
    • Neonatal Intensive Care Unit (NICU) not documenting
  • Education and training were needed
publicizing hepatitis b birth dose 2000
Publicizing Hepatitis B Birth Dose, 2000
  • Published results in Immunization Newsletter by hospital name (>10,000 readers)
    • Reinstating/implementing written policies and standing orders to OFFER birth dose to all infants (based on survey results)
    • 82 of 102 (80%) hospitals had policies in place to offer hep B to all newborns
  • Generated many calls
    • Discussed hospital process
      • Reporting birth dose information to state
      • Documenting birth dose on EBC (yes and date)
  • Continued to update and publish list quarterly
publicizing hepatitis b birth dose 2002
Publicizing Hepatitis B Birth Dose, 2002
  • Published article that listed hospitals by name
    • Written policies and standing orders to offer hep B vaccine to ALL newborns

AND

    • Birth dose coverage levels > 90% (based on MCIR data)
      • 32 of 102 hospitals named (31%)
  • Caused concern among hospitals and prompted
    • More calls
    • Hospitals to re-evaluate their systems
    • State to verify birth data
ongoing activities
Ongoing Activities
  • Presentations
  • Created and distributed program manual
  • Conduct hospital surveys
    • Identify/update contacts
  • Listserv for hospital and LHD contacts
    • Provide updates on policy/procedure information
    • Provide program manual updates annually
    • Distribute hep B birth dose coverage level reports semi-annually
  • Direct contact (phone call, e-mail or site visit)
hepatitis b birth dose coverage levels mcir
Hepatitis B Birth Dose Coverage Levels - MCIR
  • MCIR hep B birth dose coverage levels (within 4 days of life)
    • 76% in 2004
    • 78% in 2005
    • 80% in 2006
    • 81% in 2007
hepatitis b birth dose coverage levels nis
Hepatitis B Birth Dose Coverage Levels - NIS
  • Hep B birth dose coverage levels from the National Immunization Survey (NIS) are within 2 days of life
  • 2006 Michigan ranks 3rd highest in nation
    • National: 48.8% + 1.1
    • Michigan: 78.3% + 5.0
    • Detroit, MI: 81.7% + 5.6
new ebc hepatitis b birth dose and hbig reporting 2007
New EBC - Hepatitis B Birth Dose and HBIG Reporting, 2007
  • Created new web based electronic birth certificate (EBC) worksheet
  • HBIG was added
  • New EBC now includes:
    • Hep B vaccine
    • HBIG
universal hepatitis b vaccination program 2003
Universal Hepatitis B Vaccination Program, 2003
  • Continuous need to evaluate and improve methods
  • Developed Enrollment Form with MI’s Vaccines for Children (VFC) Program which requires hospitals:
    • Minimal paperwork
    • Complete profile table
      • Total annual number of births who were:
        • Enrolled in Medicaid
        • Uninsured
        • American Indian/Alaska Native
        • Underinsured/Fully insured/Private Pay
funding of universal program
Funding of Universal Program
  • Develop annual population estimates to determine annual allocation of federal funds
    • Michigan’s birth cohort x $9.50 = ($1,200,000)
    • Estimate 46% are VFC eligible (enrolled in Medicaid, uninsured, American Indian, Alaska Native, and those underinsured served at FQHC/RHC)
    • 54% served by 317/state funding (insured, underinsured) = ($648,000)
hospital enrollment process
Hospital Enrollment Process
  • Hospital eligibility information based on:
    • Registry data (preferred)
    • Billing data
    • Tally Sheets
    • Prior year’s ordering data
    • Doses administered report
  • Shipping information (site days/hours of operation)
  • Forms due to state by February 15th
recruiting hospitals to program
Recruiting Hospitals to Program
  • VFC provides a list of hospitals not enrolled
  • Call LHD to determine if there are specific issues/corrective action plans
  • Contact hospital pharmacy manager/director to discuss:
    • Barriers
    • Universal Program
    • Recommendations
    • Ease of obtaining hep B vaccine
    • Cost savings
assessing enrollment process
Assessing Enrollment Process
  • 2004
    • 54 of 95 birthing hospitals enrolled (57%)
  • 2005
    • Identified barriers
      • Too much paperwork
      • Didn’t know about process or program
      • Purchased their own vaccine
    • Worked to increase participation
      • 2005: 86 of 95 (91%) enrolled
      • 2006: 88 of 95 (93%) enrolled
      • 2007: 92 of 94 (98%) enrolled
summary
Summary
  • Ensure hospitals have written policies and standing orders
  • Consider establishing a Universal Program and enroll hospitals
  • Encourage hospitals to give hep B birth dose to all infants
  • Provide feedback to counties and hospitals on birth dose coverage levels
  • Continue to provide education and materials
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