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Lisa Jacques-Carroll, MSW NCIRD, CDC. Session 4: Delivery Hospital as Safety Net. Learning Objectives. Explain how to work with delivery hospitals in the prevention of perinatal hepatitis B infection

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learning objectives
Learning Objectives
  • Explain how to work with delivery hospitals in the prevention of perinatal hepatitis B infection
    • describe the importance of delivery hospitals in preventing perinatal hepatitis B virus (HBV) transmission
    • identify methods health departments can use to work with delivery hospitals
overview
Overview
  • Background
  • ACIP-recommended hospital policies
  • Education/working with hospitals
  • Assessing hospitals
  • Hepatitis B vaccination at birth
slide4

Rationale for Birth Dose Hepatitis B Vaccine

  • Provides safety net to prevent perinatal HBV infections
  • Prevents 70%-95% of transmission to infants born to HBsAg-positive women
  • Protects children born to HBsAg-negative women from household transmission

I got hepatitis B vaccine at birth

importance of delivery hospitals
Importance of Delivery Hospitals
  • Delivery hospital is the safety net to prevent perinatal hepatitis B:
    • last opportunity to determine pregnant woman’s HBsAg status
    • immunoprophylaxis for infants born to HBsAg-positive/unknown-status women
    • hepatitis B birth dose to all newborns
2004 u s birth statistics
2004 U.S. Birth Statistics*
  • 95.3% of births to women known to have received prenatal care (at least one visit)
  • 99.1% of births occurred in a hospital
  • 24.1% of births were to foreign-born mothers

*Source: NCHS 2004 Birth Certificate Data

slide7

HBsAg Prevalence Among Pregnant

Women by Prenatal Screening Status

Philadelphia, 1991

Prenatal

# of Women

HBsAg-positive

Screening

Tested

# (%)

Yes

1,555

12 (0.8)

No

208

14 (6.7)

Source: JAMA 1991;266:2852-5

cdc 2006 national hepatitis b hospital survey preliminary data
CDC 2006 National Hepatitis B Hospital Survey- Preliminary Data
  • Medical record reviews of 191 delivery hospitals revealed:
    • discrepancies in maternal HBsAg-status between maternal and infant records
    • hep B vaccine NOT given within 12 hours to:
      • 17%infants born to HBsAg-positive women
      • 39% infants born to unknown status women
    • HBIG NOT given within 12 hours to:
      • 33%infants born to HBsAg-positive women
      • 96% infants <2000g born to unknown-status women
acip recommended hospital policies on admission
ACIP-Recommended Hospital Policies: On Admission
  • On admission for delivery:
    • review HBsAg status of woman
    • include copy of original lab report in maternal and infant medical records
    • perform HBsAg testing on women who:
      • do not have a documented result
      • are high risk*
      • had 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 policies after delivery
ACIP-Recommended Hospital Policies: After Delivery
  • After delivery:
    • administer appropriate prophylaxis to infants* born to HBsAg-positive and unknown-status women
    • determine status of HBsAg-unknown women
    • administer a dose of hepatitis B vaccine to all newborns
    • educate HBsAg-positive women about HBV

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

acip recommended hospital policies at discharge
ACIP-Recommended Hospital Policies: At Discharge
  • At the time infant is discharged:
    • provide infant’s immunization record to mother, and
    • remind her to take it to infant’s healthcare provider
educate hospitals on policies
Educate Hospitals on Policies
  • Educate hospitals on policies and standing orders that should be in place to prevent perinatal hepatitis B transmission
educate hospitals on reporting
Educate Hospitals on Reporting
  • Encourage hospitals to report all infants born to HBsAg-positive women
    • consider a reporting form for hospitals to fax to health department
      • include HBIG and hepatitis B documentation
    • educate hospital staff on documenting on universal reporting mechanisms (if applicable)
      • maternal HBsAg status
      • infant HBIG and hepatitis B vaccination
case management at hospitals
Case Management at Hospitals
  • Notify hospitals of HBsAg-positive women who plan to deliver at their facility
    • some programs send monthly lists to hospitals
  • Remind hospitals to:
    • follow-up on HBsAg-unknown status women
    • treat infants born to HBsAg-positive and unknown-status women
    • report infants born to HBsAg-positive women
hospital quality improvement
Hospital Quality Improvement
  • Carefully review care received by each infant born to an infected woman
    • identify any gaps/errors that occurred at the hospital
    • communicate these gaps/errors to appropriate hospital staff
    • report perinatal infections to Joint Commission if errors occurred at delivery
assessing hospitals
Assessing Hospitals
  • Conduct hospital policy surveys and medical record reviews every five years at delivery hospitals to evaluate policies and practices on:
    • maternal HBsAg screening
    • post-exposure prophylaxis (PEP) to infants born to HBsAg-positive and unknown women
    • universal hepatitis B birth dose vaccination
assessing hospitals cont d
Assessing Hospitals- cont’d
  • Consider conducting medical record reviews targeting unknown status women to ensure infants receive appropriate care
    • use vital statistics birth data for women with no prenatal care
    • partner with other health department staff (HIV, STD) to review records
slide19

NIS Birth Hepatitis B Vaccination Coverage*, 2006

NYC

Philly

Chicago

DC

Coverage (%)

<30

San Antonio

Houston

30-49

50-69

* 0-2 days from birth

> 70

hepatitis b vaccination at birth
Hepatitis B Vaccination at Birth
  • Monitor state, city, and hospital-level hepatitis B birth dose rates (using National Immunization Survey (NIS), Immunization Information System (IIS), and/or medical record reviews)
  • Work with hospitals with low birth dose rates to identify barriers and increase coverage
birth vaccination cont d
Birth Vaccination- cont’d
  • Encourage hospitals to incorporate administration of the birth dose into routine infant care
  • Encourage delivery hospitals to enroll in the Vaccines for Children Program (VFC) to receive vaccine at no charge for VFC-eligible newborns
  • Projects with a universal birth dose vaccine supply have higher NIS birth dose rates
conclusion
Conclusion
  • Delivery hospitals are the safety net to prevent hepatitis B virus transmission to newborns