Texas Perinatal Hepatitis B Prevention Program 2 nd Bi-Annual State Conference

1. Designing an Effective Case Management Program Lisa Jacques-Carroll, MSW CDC, Immunization Services Division May 11, 2010 Texas Perinatal Hepatitis B Prevention Program2nd Bi-Annual State Conference

2. Learning Objectives • Describe case management of HBsAg-positive and unknown pregnant women • Describe case management of infants born to women with positive or unknown HBsAg status • Describe case management of sexual and household contacts of pregnant women with HBsAg positive or unknown status • Define provider partnerships

3. Components of Case Management • Case initiation • Education of mother • Treatment and management of infant • Management of household and sexual contacts • Monitoring and evaluation of outcomes

4. Background on Case Management

5. Benefits of Case Management • Case managed infants are more likely to receive post-exposure prophylaxis (PEP) at birth and to complete their vaccine series on time • Household and sexual contacts are more likely to be tested and vaccinated

6. Case Management in Perinatal Hepatitis B Virus (HBV) Prevention: State Examples Sources: Brian Wheeler, Alabama Dept of Public Health, 2004; MMWR 1996;45:584–7

7. Case Initiation

8. Timing of Identification • The management of an HBsAg-positive pregnant woman varies depending upon when she is identified: • prenatally • at delivery • postnatally

9. Prenatal Case Initiation • Contact prenatal care provider to confirm: • HBsAg test results • date of test • expected date of delivery • expected delivery hospital • whether woman has been evaluated for her HBV infection • Notify the delivery hospital

10. Prenatal Case Initiation - cont’d • Contact the woman to provide education and information • Identify sex partners and household contacts for testing, vaccination, and follow-up

11. Tips for working with the Mother • Use mother’s first language • Use materials with visual aids/low reading level (if appropriate) • Provide materials for review at home • Reinforce messages with follow-up letters • immediately after first interview • just before due date • before each vaccination is due • before post-vaccination testing

12. Prior to Delivery • Remind woman and delivery hospital of importance of post-exposure prophylaxis for infant at birth • consider giving woman card to take to hospital with instructions on care of infant • consider sending hospitals monthly list of HBsAg-positive women expected to deliver

13. After Expected Date of Delivery • Contact hospital to determine: • date of delivery • date/time of hepatitis B vaccine and HBIG • updated contact information for mother

14. HBsAg+ Woman Identified at Delivery or Post-natally • Contact mother ASAP to provide information on hepatitis B virus • Ensure infant received hepatitis B vaccine and HBIG • Proceed with case management of infant • Identify and manage sex partners and household contacts

15. Education of the Mother

16. Education of Mother Discuss with HBsAg+ pregnant woman: • What test results mean • Typical course of HBV infection • Seriousness of infection in newborns • How infant will be managed • Perinatal concerns (e.g., breastfeeding is safe)

17. Education of Mother - cont’d • How she can take care of herself • Importance of evaluation for HBV infection • Referral to physician for evaluation • How to prevent transmission to others • Importance of identifying/vaccinating sex partners and household contacts

18. Treatment and Management of Infant

19. Management of Infant >2000g at Birth • Mother isHBsAg positive • hepatitis B vaccine within 12 hours of birth • HBIG within 12 hours of birth • Mother isHBsAg status unknown • hepatitis B vaccine within 12 hours of birth • test mother for HBsAg ASAP • if mother is HBsAg-positive  give HBIG to infant ASAP but no later than 7 days after birth

20. Management of Infant <2000g at Birth • Mother isHBsAg positive • hepatitis B vaccine within 12 hours of birth • HBIG within 12 hours of birth • Mother isHBsAg status unknown • hepatitis B vaccine within 12 hours of birth • HBIG within 12 hours of birth • test mother for HBsAg ASAP

21. After Birth to HBsAg+ Woman • Remind pediatrician and parents • need for infant to receive hepatitis B vaccine series on time • need for post-vaccination testing of HBsAg and anti-HBs at 9-18 months of age; after 3 doses of vaccine • Verify dates hepatitis B vaccines were given • Review post-vaccination test results with pediatrician

22. Infant Post-Vaccination Test Results • If HBsAg-negative & anti-HBs >10 mIU/mL  infant is protected • If HBsAg-negative & anti-HBs <10 mIU/mL  revaccinate with 3-dose hep B series  retest 1–2 months after final dose • If HBsAg-positive  refer infant for medical evaluation/ management of chronic HBV infection  report perinatal infection to CDC via NNDSS (National Notifiable Disease Surveillance System)

23. Household and Sexual Contacts

24. Management of Contacts • Identify all household and sexual contacts of HBsAg-positive pregnant woman • Refer contacts for serologic testing • Refer susceptible contacts for hepatitis B vaccination • Refer infected contacts for medical evaluation

25. Program Outcomes

26. Completion of Follow-up for Infants of HBsAg-Positive Women, U.S.,1993-2008 HBIG/vaccine at birth 95% 3 doses by 8 months 69% Post-vaccination testing 53% Source: National Center for Immunization and Respiratory Diseases, CDC

27. TX Case Management Outcomes*, 2008 *For case managed infants. Texas data excludes Houston and San Antonio.

28. Methods to Increase Outcomes

29. Reminder and Recall Systems • Notify before (reminder) and after (recall) vaccines and tests are due • Use for parents, pediatricians, and case workers • How? • postcards filled out by parent to be mailed by provider or health department • computer-generated letters • phone calls • prompts for case workers follow up

30. Data Integration • Some programs’ perinatal hepatitis B data are integrated into other systems: • Immunization Information System (IIS) • infant hepatitis B vaccinations in this system • Communicable disease reporting system • HBsAg-positive women reported to this system

31. Increase PVS Testing • Utilize electronic systems such as state Medicaid database or immunization registry to find updated contact info • Provide incentives to families to get infants tested ($10 gift cards) • Keep cases open for longer/persistent case managers

32. Working with Hospitals and Providers • Ongoing need for education of delivery hospital staff, prenatal care providers, family practitioners and pediatricians on their roles in perinatal hepatitis B prevention

33. Educating Prenatal Care Providers • Remind prenatal care providers to screen all pregnant women for HBsAg and report infected women to public health • Encourage providers to educate all pregnant women on the birth dose of hepatitis B vaccine

34. Educating Delivery Hospitals • Conduct policy reviews and medical record reviews • Assure hospitals have policies: • Universal birth dose administration • Review/test all delivering women for HBsAg • PEP for infants born to HBsAg-positive and unknown women • Report all cases to the health department

35. Educating Pediatricians • Encourage administration of birth dose of HepB for all infants • Educate on importance of timely receipt of HepB series for infants born to HBsAg-positive women and PVS testing

36. Working with Community Organizations • Engage with community organizations to help educate key players on their roles and responsibilities in perinatal hepatitis B prevention

37. Provider Partnerships • Develop relationships with local providers • Identify provider champions to help educate other providers and implement hospital policies • Work with local ACOG and AAP chapters

38. Evaluate Your Progress

39. Evaluating Case Management • Proportion of infants receiving: • HepBvaccine & HBIG within 12 hours of birth • on-time completion of HepBvaccine series • post-vaccination testing • Reasons for cases lost to follow-up • Proportion of screened and vaccinated household and sexual contacts

40. Evaluating Case Mgmt - cont’d • Monitor case management outcomes: • compare program-wide rates to national rates • locally (county level) • quarterly or monthly • over time (trends)