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Elizabeth Lawlor, Advanced Epidemiologist

Maternal, Infant, and Hospital Level Factors Associated with Newborn Hepatitis B Vaccination – Kansas, 2009. Elizabeth Lawlor, Advanced Epidemiologist. Background. Hepatitis B. Caused by hepatitis B virus (HBV) ~ 4.4 million in US living with chronic HBV Often asymptomatic Transmission

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Elizabeth Lawlor, Advanced Epidemiologist

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  1. Maternal, Infant, and Hospital Level Factors Associated with Newborn Hepatitis B Vaccination – Kansas, 2009 Elizabeth Lawlor, Advanced Epidemiologist

  2. Background

  3. Hepatitis B • Caused by hepatitis B virus (HBV) • ~ 4.4 million in US living with chronic HBV • Often asymptomatic • Transmission • Sexual • Parenteral • Perinatal • Perinatal: infection of infant after birth • Risk of perinatal HBV infection among infants born to HBV+ mothers ranges from 10%-85%

  4. Chronic HBV • Major cause of: • Cirrhosis of the liver • Primary hepatocellularcarcinoma • Development of chronic HBV is age dependent • Primary develops into chronic infection • 5% of healthy older children and adults • 30% of children <5 years old • 90% of infants

  5. Chronic HBV • ~ 25% of infected infants will develop: • Chronic liver disease • Cirrhosis • Hepatocellular carcinoma • ~ 25% of infants with complications will die as young adults

  6. Outcome of HBV Infection by Age at Infection 100 100 80 80 60 60 Chronic Infection Chronic Infection (%) Symptomatic Infection (%) 40 40 20 20 Symptomatic Infection 0 0 1-6 months 7-12 months Older Children and Adults Birth 1-4 years Ward, John and Prevention, Centers for Disease Control and. Hapatitis A Through E: An Overview. University of Alabama at Birmingham. [Online] 2007. www.microbio.uab.edu/medmicro/lectures/ward.ppt.

  7. Preventing Perinatal Infections • Hepatitis B immune globulin (HBIG) and HBV vaccine birth dose administered at birth • ≥ 95% effective at preventing infection for infants born to HBV+ moms • HBV vaccine (without HBIG) is 70% - 95% at preventing transmission from mother to child • Several case reports of infants contracting HBV because of no chemoprophylaxis at birth • HBV birth dose recommended for all medically stable infants > 2,000 grams regardless of maternal status Centers for Disease Control and Prevention. Recommendations of the Advisory Committee on Immunization Practices (ACIP). A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States: Immunization of Infants, Children, and Adolescents. MMWR. 2005, Vol. 54, RR16. Centers for Disease Control and Prevention. Recommendations of the Immunization Practices Advisory Committee Prevention of Perinatal Transmission of Hepatitis B Virus: Prenatal Screening of all Pregnant Women for Hepatitis B Surface Antigen. MMWR. 1988, Vol. 37, 22.

  8. Universal Birth Dose Policy • Provided by Kansas Department of Health and Environment (KDHE) to hospitals enrolled in Vaccines For Children program • Hepatitis B vaccine is offered, at no cost, for all infants regardless of insurance status

  9. Objective • To determine what factors are associated with hepatitis B birth dose receipt at Kansas hospitals

  10. Methods

  11. Study • Retrospective cohort study • Data sources • Hospital policy survey • 2009 birth registry data

  12. Hospital Policy Survey • Survey was sent to all birthing hospitals’ labor and delivery units • Assessed 2009 policies • Policies to prevent perinatal infections (hepatitis B, HIV, and group B strep) • Policies regarding universal newborn hepatitis B birth dose administration

  13. Independent Variables (Individual Level) • Maternal factors – birth registry • Age (continuous) • Race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, other) • Education (less than high school, high school/GED, some college, college degree and higher) • Insurance (private, Medicaid, self-pay) • Receipt of prenatal care (Y/N) • Attending provider (MD, DO, midwife) • Infant factors – birth registry • Plurality (singleton, multiple)

  14. Independent Variables (Hospital Level) • Hospital Characteristics • Hospital size (≤ 500, > 500) • Urbanicity (urban, non-urban) • Written hospital vaccination policy (Y/N) • Policy Survey

  15. Dependent Variable • Vaccination with hepatitis B vaccine prior to discharge (Y/N) • Recorded on the birth certificate

  16. Record Exclusion • Excluded the following from analysis: • Infants weighing < 2,000 grams • Infants born outside of a hospital • Infants with unknown values for independent variables

  17. Statistical Analysis • Analyses were performed using SAS® 9.3 • Bivariate associations assessed • Birth dose and maternal/infant factors • Birth dose and hospital factors • Stepwise multivariable logistic regression to assess the association of maternal, infant, and hospital level characteristics with infant hepatitis B immunization prior to discharge • Goodness-of-fit test and pseudo R2

  18. Statistical Analysis • Multilevel logistic regression analysis was performed • Level 1 – individual characteristics (maternal/infant) • Level 2 – hospital characteristics • Preliminary results

  19. Results

  20. Policy Survey • Responses from 68 of 73 (93%) of hospitals

  21. Birth Dose Administration • 2009 Births • 42,512

  22. Birth Dose Administration • 2009 Births • 42,512 • Excluded • 6,106 (14%)

  23. Birth Dose Administration • 2009 Births • 42,512 • Excluded • 6,106 (14%) • No Policy Survey • 4,340 (10%)

  24. Birth Dose Administration • 2009 Births • 42,512 • Excluded • 6,106 (14%) • No Policy Survey • 4,340 (10%) • Included in Analysis • 32,066 (75%)

  25. Birth Dose Administration • 2009 Births • 42,512 • Excluded • 6,106 (14%) • No Policy Survey • 4,340 (10%) • Included in Analysis • 32,066 (75%) • Received birth dose • 25,843 (80.6%)

  26. Birth Dose Administration • 2009 Births • 42,512 • Excluded • 6,106 (14%) • No Policy Survey • 4,340 (10%) • Received birth dose • 3,518 (81.1%) • Included in Analysis • 32,066 (75%) • Received birth dose • 25,843 (80.6%)

  27. Bivariate Analysis – Individual • Maternal • Age • Education • Race/ethnicity • Attending provider • Prenatal care • Pay source • Infant • Plurality

  28. Bivariate Analysis – Individual • Maternal • Age • Education • Race/ethnicity • Attending provider • Prenatal care • Pay source • Infant • Plurality Significant

  29. Bivariate Analysis – Hospital • Number of births • Urbanicity • Vaccination orders

  30. Bivariate Analysis – Hospital • Number of births • Urbanicity • Vaccination orders Significant

  31. Logistic Regression • Individual factors • Age • Hispanic ethnicity • Maternal education • Private insurance • Plurality • Attending (DO) • Hospital factors • Number of births • Urbanicity • Vaccination orders GOF p = 0.67 Pseudo R2 = 0.25 Significant: p < 0.05

  32. Individual factors • Age • Hispanic ethnicity/other race • High school education or less • Plurality • Prenatal care • Hospital factors • Vaccination orders Multilevel Analysis

  33. Conclusions

  34. Discussion • Maternal, infant, and hospital level characteristics are associated with receipt of the birth dose • Disparities exist at both the individual and hospital level

  35. Discussion • Maternal education • Less education is significantly associated with birth dose administration – higher educated women are more likely to question physicians • Maternal race/ethnicity • Hispanic ethnicity and races other than white non-Hispanic and black non-Hispanic are more likely to have vaccinated • Plurality • Potentially due to greater involvement of physicians in infants’ care as opposed to singletons?

  36. Discussion • No variation between urban and rural hospitals, or between large and small hospitals • Vaccination orders • Presence of orders was most significantly associated with the administration of the birth dose • Should be implemented at all hospitals

  37. Limitations • Birth dose data from the birth registry • Possible incorrect reports from hospitals • No data on 5 hospitals’ policies • Multilevel analysis did not address interactions

  38. Recommendations • Educational efforts are needed regarding importance of the vaccine • Continued education of hospitals on importance of birth dose • Further examination of the multilevel logistic regression model is needed, including other hospital factors (e.g. teaching status, ownership type, etc.)

  39. Acknowledgements • Suparna Bagchi, PhD – EIS officer • KDHE-BEPHI staff • Public Health Informatics • Infectious Disease Epidemiology and Response • CSTE

  40. Questions?

  41. Elizabeth Lawlor, MS Advanced Epidemiologist Bureau of Epidemiology and Public Health Informatics Kansas Department of Health and Environment 785-368-8208 elawlor@kdheks.gov

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